- 


PRACTICAL  DIETETICS 


PRACTICAL  DIETETICS 


WITH  SPECIAL  REFERENCE  TO 
DIET  IN  DISEASES 


W.   GILMAN  THOMPSON,   M.  D. 

PROFESSOR  OF  MEDICINE  IN  THE  CORNELL  UNIVERSITY  MEDICAL  COLLEGE 

IN   NEW   YORK  CITY 
VISITING  PHYSICIAN  TO  THE  PRESBYTERIAN  AND  BELLEVUE  HOSPITALS 


"Good  diet  with  wisdom  best  comforteth  men  " 

TUSSER  (1520) 


FOURTH  EDITION,  ILLUSTRATED,  ENLARGED  AND 
COMPLETELY  REWRITTEN 


NEW  YORK  AND  LONDON 

D.    APPLETON    AND    COMPANY 

1909 


COPYRIGHT,  1895,  1902,  1905,  1909,  BY 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS, 
NEW  YORK,  U.  S.  A. 


A/ 


PREFACE  TO  THE  FOURTH  EDITION 

Since  the  publication  of  the  first  edition  of  this  work  in  1895,  great 
progress  has  been  made  in  the  study  of  dietetics. 

The  scientific  aspect  of  the  subject  has  been  notably  advanced 
through  the  extensive  researches  of  the  Department  of  Agriculture  in 
Washington,  and  of  the  allied  Agricultural  Experiment  Stations  in 
many  different  States,  where  food  analyses,  calorimetry  computations, 
and  investigations  of  the  dietetic  habits  of  different  races  and  classes 
of  men  have  done  much  towards  placing  the  hitherto  vague  subject  of 
dietetics  upon  an  accurate  scientific  basis.  In  university  and  medical 
college  laboratories  much  independent  research  has  been  devoted  to 
the  relationship  between  ingested  food  and  excreta,  and  the  complex 
processes  of  food  metabolism  in  health  and  disease. 

In  hospitals  more  and  more  attention  is  being  directed  to  the  prep- 
aration of  food  in  diet  kitchens  for  the  sick,  and  more  thorough  in- 
struction is  being  given  to  nurses  in  the  proper  feeding  of  patients. 

The  medical  profession  in  general  has  evinced  increasing  interest  in 
accuracy  in  dietetic  methods,  and  special  progress  has  been  made  in 
the  dietetic  treatment  of  such  important  and  common  diseases  as 
chronic  nephritis,  typhoid  fever,  diabetes,  intestinal  autointoxication, 
and  the  gastrointestinal  disorders  of  infancy  and  childhood. 

In  order  to  include  a  full  discussion  of  all  these  topics,  as  well  as 
the  accumulated  experience  of  the  writer,  the  present  edition  has  been 
completely  rewritten  and  75  pages  have  been  added  to  the  text  together 
with  42  new  illustrations. 

It  is  the  design  of  the  work  to  furnish  a  source  in  which  the  ac- 
cepted method  of  dieting  will  be  found  for  each  condition  or  disease 
amenable  to  dietetic  influence.  To  this  end  many  brief  tables  and 
summaries  of  dietetic  directions  are  appended  to  the  discussion  of  the 
scientific  principles  involved  in  each  case. 

The  reader  also  will  find  a  discussion  of  representative  dietaries  of 
hospitals  and  various  Government  institutions,  and  sections  upon  the 
proper  dieting  at  various  stages  of  life  from  infancy  to  old  age,  for 
various  special  occupations,  for  increasing  or  diminishing  body  weight, 

v 


26497 


VI  PREFACE 

etc.,  and  a  section  is  devoted  to  consideration  of  the  difficult  problems 
which  arise  when  diseases  demanding  opposite  methods  of  dieting, 
exist  in  combination.  Numerous  cross  references  and  a  full  index  are 
added  to  aid  in  elucidating  the  text. 

The  author  disclaims  advocacy  of  any  special  dietetic  theory  or  "sys- 
tem." No  one  food  is  curative  of  any  disease,  just  as  no  one  food 
may  be  said  to  be  causative  of  any  disease. 

It  is  rarely  feasible  to  feed  the  sick  upon  any  system  of  accurate 
food  weighing,  laboratory  calculations  of  calories,  or  the  results  of 
single  analyses  of  gastric  contents.  Such  systems  add  scientific  in- 
terest to  the  general  subject  of  dietetics,  but  the  problems  of  right 
feeding  in  disease  must  be  studied  in  the  light  of  clinical  experience, 
and  modified  to  meet  ever  changing  conditions.  One  of  the  com- 
monest of  dietetic  errors  is  the  too  long  continuance  of  a  dietary  which, 
although  at  first  beneficial,  may  result  in  anaemia  or  asthenia  by  be- 
coming monotonous  or  failing  to  meet  all  the  complex  demands  of 
nutrition. 

These  principles,  which  form  the  basis  of  the  book,  have  been  still 
further  emphasized  in  the  present  edition. 

W.  OILMAN  THOMPSON,  M.D. 


The  subject  of  the  dietetic  treatment  of  disease  has  not  received 
the  attention  in  medical  literature  which  it  deserves,  and  it  is  to  be 
regretted  that  in  the  curriculum  of  medical  colleges  it  is  usually 
either  omitted  or  is  disposed  of  in  one  or  two  brief  lectures  at  the 
end  of  a  course  in  general  therapeutics.  Upon  examining  the 
standard  treatises  upon  the  Theory  and  Practice  of  Medicine,  as  well 
as  monographs  upon  important  diseases,  such  as  those  of  the  cir- 
culation, nervous  system,  and  skin,  one  cannot  fail  to  be  impressed 
with  the  meagre  notice  given  to  the  necessity  of  feeding  patients 
properly,  and  the  subject  is  usually  dismissed  with  such  brief  and 
indefinite  phrases  as  "The  value  of  nutritious  diet  requires  mere 
mention,"  "A  proper  but  restricted  diet  is  recommended,"  and  fa* 
vorite,  if  not  convincing,  expressions  are,  "  The  patient  should  be 
carefully  fed,"  and  "  General  dietetic  treatment  is  of  primary  impor- 
tance." With  such  vague  directions  the  dieting  must  indeed  be 
very  "  general." 

In  many  excellent  works  upon  food  and  dietetics  the  space  devoted 
to  the  practical  application  of  dietetics  to  disease  is  comparatively 
insignificant,  and  much  less  emphasis  is  given  to  this  matter  in  hos- 
pitals and  in  the  training  of  nurses  than  is  demanded  in  the  interests 
of  medical  science. 

A  writer  of  wide  experience  in  practical  dietetics,  Mrs.  F.  H.  Rich- 
ards, says :  "  At  present  there  are  comparatively  few  persons  who 
are  called  upon  to  feed  the  sick  to  whom  a  glass  of  milk  or  a  pound 
of  beef  represent  any  definite  amount  of  food  materials.  Still  fewer 
who  can  tell  how  much  food  value  a  glass  of  lemon  jelly  or  wine  whey 
represents,  and  yet  the  adult  patient  is  dependent  upon  the  attendant 
even  more  than  the  week-old  infant  for  the  requisite  nutrition." 

The  present  volume  has  been  prepared  with  the  view  'of  in  some 
measure  making  good  such  deficiencies  by  furnishing  a  text-book  in 
which  the  practitioner  of  medicine  may  find  detailed  the  appropriate 
diet  for  each  disease  which  is  at  all  influenced  by  right  feeding. 

vii 


viii  PREFACE 

Quite  as  much  depends  upon  the  suitable  preparation  of  food  as 
upon  the  selection  and  limitation  of  food  itself,  and  it  has  therefore 
been  thought  advisable  to  include  a  general  account  of  the  composi- 
tion and  uses  of  foods,  and  the  changes  which  may  be  produced  in 
them  by  cooking  and  other  processes.  In  this  first  portion  of  the  work, 
however,  the  practical  application  of  such  knowledge  to  the  feeding  of 
the  sick  has  been  constantly  emphasized  rather  than  unnecessary 
scientific  detail. 

The  reader  will  also  find  a  discussion  of  representative  hospital 
dietaries,  the  official  dietaries  of  Government  institutions,  and  sections 
upon  the  proper  feeding  of  infants  and  children.  Numerous  cross 
references  and  a  complete  index  have  been  added  to  avoid  undue 
repetition. 

Bennett  wrote,  as  long  ago  as  1858 :  "  Of  all  the  means  of  cure 
at  our  disposal,  attention  to  the  quantity  and  quality  of  the  ingesta 
is  by  far  the  most  powerful."  While  fully  concurring  in  this  view, 
that  appropriate  dieting  is  often  more  needed  than  medication,  I  dis- 
tinctly disclaim  the  advocacy  of  any  special  dietetic  system  as  a  cure- 
all,  as  well  as  the  specific  influence  of  any  one  food  in  the  general 
treatment  of  disease.  It  cannot  be  expected  that  the  experience  of 
a  single  individual  should  cover  so  extensive  a  ground  as  that  which 
embraces  the  relative  advantages  of  all  foods,  and  I  have  therefore 
impartially  introduced  the  views  of  others,  especially  where,  as  in 
such  diseases  as  gout,  diabetes,  and  obesity,  opposing  dietetic  theories 
are  held  by  clinicians  of  extensive  experience  and  authority.  Due 
acknowledgment  of  these  references  is  made  in  the  text,  but  the  ad- 
mirable researches  upon  foods  of  our  own  Government,  found  in  the 
published  reports  of  the  Department  of  Agriculture,  are  especially  to 
be  commended. 

W.  GILMAN  THOMPSON. 


CONTENTS 

PART  I 

FOODS  AND  FOOD  PREPARATIONS 

PAGE 

Elementary  composition  of  foods 1 

Food  classification .   .   .        .        -4 

Force  production.     Energy  from  food 6 

Force-producing  value  of  the  different  classes  of  foods        ....  19 

I.  Water         ..." 19 

II.  Salts 19 

III.  Proteids,  carbohydrates,  and  fats 19 

Oxygen  and  food '  r, 24 

Stimulating  foods 25 

Economic  value  of  food 25 

Nutrition.     Animal  and  vegetable  foods  compared 29 

Vegetarianism 33 

The  classes  of  foods 36 

I.  Water «'.-.'.        .36 

Uses  of  water  in  the  body 37 

Purity  of  water 38 

Varieties   of   drinking  water 38 

Special  dietetic  uses  of  water 40 

Excess  of  water 41 

Deprivation  of  water.     Water  starvation 42 

Temperature  of  drinking  water .44 

II.  Salts 44 

Varieties  of  salts 44 

Uses  of  salts  in  foods 44 

Excess  of  salt 45 

Deprivation  of  salt 45 

Sodium 46 

Potassium 47 

Calcium 47 

Phosphorus 48 

Sulphur 48 

Iron 48 

Vegetable  acids 48 

III.  Animal   foods 49 

Milk 49 

Exclusive  milk  diet .50 

Physical  properties  of  milk  .            51 

Chemical  composition  of  milk 52 

Milk  ferments  .... 58 

Varieties  of  milk             .            58 

ix 


CONTEXTS 

PAGE 

Methods  of  milk  analysis       .           63 

Milk  adulteration  and  impurities 70 

Milk  contamination     .        .        . 72 

Prophylaxis  against  milk  infection 

Uses  of  milk 

Milk  digestion 

Adaptation  of  milk  for  the  sick 

Methods  of  altering  the  taste  of  milk       . 
Methods  of  improving  the  digestibility  of  milk 

Methods  of  predigestion,  sour  milk, 'etc 

Peptonized  milk !)0 

Pancreatinized  milk 90 

Koumiss 93 

Methods  of  sterilization,  Pasteurization,  and  preservation   .        .  96 

Sterilized  milk 96 

Pasteurized  milk 100 

"  Humanized  milk  " 103 

Modified  milk.     Milk  laboratories 103 

Milk  derivatives 108 

Condensed  milk 108 

Cream 109 

Butter 112 

Buttermilk 114 

Cheese 114 

Whey 119 

Eggs .120 

Raw  eggs.     Eggnog.     Egg  albumen 122 

The  cooking  of  eggs 123 

Preservation  of  eggs 124 

Meats 124 

Consumption  of  meat 124 

Structure  and  composition  of  meats 126 

Raw  meats 127 

Digestibility   of  meats 128 

Composition  of  beef 130 

Beef  preparations  for  the  sick 131 

Solid  meat  preparations 132 

Fluid  meat  preparations .  135 

Various  meats 141 

Beef  tongue 141 

Veal 141 

Mutton 141 

Lamb 142 

Venison 142 

Pork 142 

Ham  and  bacon> 142 

Horseflesh 143 

Ral.bit         .                        143 

Fowl    .         .                 143 

Game           ...                                                                                      .  144 


CONTENTS  xi 

PAGH 

Animal  viscera     , 145 

Isinglass,  gelatin 146 

Sea  Food 147 

Fish 147 

Crustaceans 150 

Shellfish  —  oysters,  clams,  scallops,  mussels 151 

Insects 152 

IV.  Vegetable  foods 152 

Sugars 152 

Sugars  and  the  urine 154 

Cane  sugar,  saccharose 154 

Caramel          .        .        .        .        .        .        . 156 

Candy  and  confectionery 156 

Molasses,  treacle,  and  syrup     .        .        . 157 

Grape  sugar,  glucose 157 

Milk  sugar 158 

Mannite • 158 

Levulose         .............  158 

Honey .   -    .        .        .        .        .  158 

Saccharin 159 

Cereals  and  other  starch-bearing  foods 159 

Starch-bearing  foods  in  general .        .  159 

Bread-making ....        .  161 

Structure  of  the  wheat  kernel      .        .        .        .        ...        .  162 

Bran .        .•      ...  162 

Gluten .       '*.        .        .  163 

Composition  of  bread 164 

Bread-baking 164 

Variety  of  bread  stuffs  and  prepared  farinaceous  foods     .        .        .  169 

Wheaten  flour  and  bread 169 

Whole-meal  bread 170 

Gluten  bread . 172 

Biscuits,  pastry,  puddings,  etc 173 

Prepared  farinaceous  foods 173 

Crackers 178 

Semolino 179 

Buckwheat 180 

Millet,  sorghum,  rye,  corn 181 

Rice .  183 

Barley •    .        .  184 

Oatmeal >..-...        .        .        .185 

Arrowroot 186 

Tapioca,  cassava 187 

Sago 187 

Iceland  moss 187 

Starchy  foods  for  children 188 

Diastase,  malt  extracts,  etc 188 

Vegetable  food  in  general 190 

Legumes,  peas,  beans,  lentils,  peanuts 192 

Roots  and  tubers 196 

2 


ll  CONTENTS 

PAGE 

Potatoes     ..........        ....   196 

Beets          .......       ......    199 

Succulent  tubers       ........       ....  200 

Green  vegetables  ............  201 

Fruits         .       .       ............  207 

Composition          ............  207 

Uses  and  properties  of  fruits  .........  209 

Fruit  ripening      ............   210 

Fruit  poisoning    ............   210 

When  to  eat  fruit       ...........  211 

Dried  fruits;  cooked  fruits       .........   211 

Digestibility  of  fruits         ..........   212 

Varieties  of  fruits       ...........  212 

Lemons,  limes,  shaddocks      .........  212 

Oranges      .............  213 

Apples        .............   214 

Pears,  peaches,  etc  ............  215 

Bananas     .............   216 

Grapes        .............  219 

Plums,  prunes  ............   220 

Berries,  strawberries,  etc.      .        ........   221 

Melons        .............   222 

Figs  and  dates  ............   223 

Fungi         ..............  224 

Lichen         ..............   225 

Nuts    ...............   226 

V.  Fats  and  oils  .............  228 

Animal  fats       ...........  ,   231 

Bone  marrow    ..........  .   223 

Vegetable  fats  and  oils  .........  .   234 

Glycerin      ..............   235 

Cod-liver  oil       ...........  .   235 

PART  II 

STIMULANTS,  BEVERAGES,   CONDIMENTS 

Stimulants  and  beverages       .......  241 

Alkaline  and  mineral  waters,  effervescing  waters      ...  243 


Tannin 
Tea 


247 
.        .        ;        ...........  247 

...........   218 

Relative  value  of  coffee  and  tea     .....  257 

Cocoa    •  ...........        .        .   258 

Cacao   butter          ......  ,t  259 

Chocolate    .......  260 

Koli>  .......  ....!.]  262 

Alcohol         .......  262 

General  discussion  of  the  value  of  alcohol       .  263 

Physiological  action     ......  265 

I.  As  a  food  ' 


CONTENTS  xiii 

PAGE 

II.  As  a  stimulant 266 

III.  Action  upon  the  muscles 267 

IV.  Action  upon  the  temperature 267 

V.  Action  as  a  diuretic 267 

VI.  Action  upon  mucous  membranes 268 

VII.  Action  upon  gastric  digestion 268 

VIII.  Alcohol  absorption 269 

IX.  Alcohol  elimination 269 

X.  Alcohol  poisoning 269 

XI.  Alcohol  and  climate 269 

Clinical  uses  of  alcohol 270 

Selection  of  proper  alcoholic  beverage 273 

Malt  liquors 274 

Beer  * 274 

Ale 275 

Porter 275 

Stout 275 

Wine 276 

Composition 276 

General  properties 276 

White  wines 277 

Red  wines 278 

Varieties  of  wines 279 

I.  String  dry  wines 279 

II.  Strong  sweet  wines 280 

III.  Aromatic  wines 281 

IV.  Acid  wines 281 

V.  Sparkling  wines 281 

VI.  "  Perfect "  wines       . 282 

VII.  Rough  wines 283 

Liquors 284 

Adulteration  of  liquors  and  wines 286 

Liqueurs  and  cordials 287 

Cider 288 

Condiments  and  spices 288 


PART  III 

COOKING. — FOOD     PREPARATION     AND     PRESERVATION. — THE     QUANTITY     OF     FOOD 

REQUIRED 

Cooking 294 

Varieties  of  cooking 295 

1.  Boiling 296 

2.  Stewing ....  298 

3.  Roasting , 299 

4.  Grilling 300 

5.  Frying 301 

6.  Braising 302 


xiv  CONTENTS 

PAGE 

7.  Baking   ...                                                       ..'.....  303 

8.  Steaming 303 

Soups       .        .        . 303 

Cooking  of  fish     . 304 

Cooking  of  vegetables 304 

Food  concentration. — Condensed  food 305 

Drying,  desiccation,  extracts 305 

Diet  of  concentrated  foods 307 

Food  preservation 308 

I.  Drying 309 

II.  Smoking 309 

III.  Salting 309 

IV.  Freezing 310 

V.  Refrigeration 310 

VI.  Sterilization 311 

VII.  Exclusion  of  air. — Canning 311 

VIII.  Antiseptic  and  preservative  substances 313 

Substitutes  for  food .  316 

Quantity  of  food  required 317 

Climate  and  season 318 

Clothing  and  food 321 

Exercise  and  food 322 

General  health  and  food 322 

Age  and  food 322 

Sex  and  food 323 

Size  and  food 324 

Weight   and  food 324 

Calculation  of  rations 325 

Forced  and  reduction  feeding 340 

Quantity  of  food  eaten  per  annum 340 

Measurement  of  food 341 

Starvation  and  inanition 343 

Voluntary  fasting 344 

Famine 359 

Improperly  balanced  diet 350 


PART  IV 

SPECIAL   CONDITIONS    INFLUENCING   FOODS 

Age  and  toou _   352 

Food   in  childhood ,   352 

Food   in  adult   life 353 

Food  in  old  age _    353 

Diet  and  heredity _    357 

Diet   and  race 35g 


CONTENTS  xv 
PART  V 

FOOD    DIGESTION. CONDITIONS    WHICH    ESPECIALLY   AFFECT   DIGESTION 

PAGE 

Digestibility  of  foods       .        .        .        ...        ...        .        .        .363 

Hours  for  meals  and  order  of  taking  food 364 

Appetite 368 

Abnormal   cravings 370 

Variety  in  diet 371 

The  nervous  system  and  digestion 373 

Circulation  and  digestion                •. 374 

Temperature  and  digestion 374 

Exercise  and  digestion 378 

Rest  and  sleep  and  digestion 380 

Mental  emotion  and  digestion 382 

Food  in  the  mouth 382 

Fletcherism 384 

Food  in  the  stomach 386 

Quantity  of  gastric  juice .  386 

Secretion  of  the  gastric  juice 387 

Hydrochloric  acid 387 

Pepsin,  albumoses,  peptones 388 

Digestion  of  proteids  in  the  stomach 389 

Abnormalities  of  gastric  digestion 392 

Food  in  the  intestine 393 

Pancreatic  juice 394 

Bile 394 

Digestion  of  fats 394 

Intestinal   gases 395 

Artificial   digestion 396 

Predigestion  of  starches 396 

Predigestion  of  proteids .                        .  397 

Food   absorption .                        ...  399 

Elimination  of  food  waste      ...                       .                ....  400 

The  feces  and  food 401 

The  urine  and  food 403 

Tobacco  and  food 404 

Food  equivalents,  food  "  portions  " 404 

PART  VI 

THE    GENERAL   RELATION    OF    FOOD    TO    SPECIAL   DISEASES. DISEASES    WHICH  ARE 

CAUSED   BY    DIETETIC   ERRORS 

The  general  relation  of  food  to  special  diseases 407 

Rules  for  prescribing  a  dietary 409 

Diseases  caused  by  dietetic  errors 

I.  Insufficient  food -411 

II.  Overeating  and   overdrinking .  411 

III.  Food  which  is  injurious  because  the  ingredients  are  not  properly 

balanced 413 


xvi  CONTENTS 

PAGE 

IV.  Food  containing  parasites  or  their  embryos 413 

Intestinal  worms -      •  413 

Trichinosis 415 

V.  Food  containing  ptomaines 419 

Poisoning  by  meat  or  game 419 

Poisoning  by  milk,  cream,  ice  cream,  and  cheese 423 

Poisoning  by  crustaceans,  shellfish,  and  fish 424 

VI.  Other  food  poisons 425 

Grain  poisoning 426 

Ergotism 426 

Lathyrism 426 

Pellagra 427 

VII.  Food  adulteration 427 

Pigments 429 

National  Bureau  of  Medicines  and  Foods 430 

Copper,  tin,  lead  and  zinc  poisoning 430 

VIII.  Food  containing  micro-organisms  of  infectious  diseases  .        .        .  432 

Milk  infection 432 

Tubercular  infection  through  milk  and  meat 432 

Typhoid  and  cholera  infection 435 

Infection  through  oysters 435 

Diphtheria  and  scarlatina 437 

Foot-and-mouth    disease 437 

Food  infection  through  flies 437 

IX.  Idiosyncrasies  in  regard  to  food 438 

X.  Alcohol  poisoning.     Alcoholism 438 

Delirium  tremens .  442 


PART  VII 

ADMINISTRATION   OF   FOOD   FOB  THE   SICK 

Methods  of  feeding  the  sick 444 

The  appetite 445 

Regularity  in   feeding .  445 

Quantity  of  food  in  illness 445 

Details  of  serving  food 446 

Feeding  helpless  patients .  447 

Sleep   and   feeding .  448 

Cleansing  the  mouth .  443 

Feeding  unconscious   patients .  449 

Nutrient   enema ta t  459 

Conditions  demanding  rectal  feeding .  451 

Method   of  injection  * _  452 

Care  of  the  rectum          .......  .  454 

Substances  available  for  rectal  feeding 455 

Prescriptions  for  food  enemata      ....  .  453 

Food  suppositories        ......  453 

Other  methods  of  feeding ^  453 


Inunction   foods 


458 


CONTENTS  xvii 

PAGE 

Intravascular  feeding 0 453 

Hypodermic  feeding 459 

Medicines   and    food 459 

Rules  for  administering  medicines  in  relation  to  food       ....  461 

Diet-kitchen  outfit 402 

Trained  purveyors  of  food 402 


PART  VIII 

DIET  IN  DISEASE. — DIET  IN  INFECTIOUS   DISEASES 

Diet  in  fever  in  general 463 

Beverages  in  fevers 468 

Alcohol  in  fevers -.  470 

Diet  in  convalescence  from  fevers 472 

Typhoid  fever 473 

Dietetic  treatment 474 

Relation  of  intestinal  antisepsis  to  diet 482 

Convalescence 483 

Rules  for  feeding  atypical  cases 485 

Typhoid  fever  in  children 487 

Typhus  fever 488 

Smallpox 488 

Scarlet   fever 489 

Measles 490 

Mumps 490 

Whooping  cough 491 

Influenza 491 

Diphtheria 493 

Intubation   and  tracheotomy 493 

Post-diphtheritic  paralysis 495 

Cerebro-spinal   meningitis 495 

Erysipelas 496 

Cholera 497 

Yellow  fever 499 

Septicaemia 502 

Malaria 503 

Tetanus 504 

Rabies 505 

Tuberculosis 505 

General    considerations 505 

Diet  in  mild  cases 511 

Diet  in  advanced  cases 513 

Suralimentation 514 

Diets  for  forced  feeding 515 

Aids  to  dietetic  treatment 517 

Diet  "  cures  "  for  phthisis 517 

Syphilis 518 


xviii  CONTENTS 

DIET    IN   DISEASES   OF   THE    RESPIRATORY    SYSTEM 

PAGE 

Laryngismus  stridulua    .        .        •  •        •        •        ••        •        •        .518 

Tubercular  laryngitis 518 

Haemorrhage  of  the  lungs      .        .        .        .        . 519 

Acute  capillary  bronchitis 520 

Chronic  bronchitis 520 

Asthma 521 

Emphysema 522 

Pneumonia 523 

Broncho-pneumonia 525 

Pleurisy 525 

Empyema 526 

DIET   IN   DISEASES   OF   THE   CIRCULATORY   SYSTEM    AND   BLOOD 

Diseases  of  the  heart 527 

Cardiac  valvular  disease  in  children 530 

Dietetic  treatment  of  the  senile  heart 530 

Angina   pectoris 533 

Cardiac  palpitation 533 

Arterio  sclerosis 534 

Aneurism 535 

TufnelPs    diet 536 

Anaemias. —  Chlorosis,  etc 537 

Pernicious  anaemia   . 543 

DIET   IN    DISEASES   OF   THE    URINARY    SYSTEM 

Influence  of  diet  on  the  urine 543 

Acute  nephritis 544 

Acute  nephritis  in  children 546 

Albuminuria  —  functional  and  organic 547 

Chronic  Bright's  disease 550 

Salt-free  diet 556 

Pyelitis 556 

Oxaluria 557 

Calculi,  renal  and  vesical 558 

Lithaemia.  Uric-acid  diathesis. —  Gravel 559 

Gonorrhoea .  562 

DIET    IN    DISEASES   OF   THE   ALIMENTARY   CANAL 

Abnormal  dentition 563 

Stomatitis 564 

Tonsilitis  and  quinsy       .........  .  564 

Dysphagia  565 

Stricture  and  carcinoma  of  the -oesophagus .  566 

Feeding  through  a  gastric  fistula 566 

Foreign  bodies   swallowed       .         .        .  567 

Indigestion  and   dyspepsia      ......  568 

Examination  of  the  stomach  contents      ...  .  572 


CONTEXTS  xix 

PACK 

Test  meals 572 

Te"sts  for  free  hydrochloric  acid 574 

Hypersecretion 576 

Tests  for  pepsin  and  rennin '  ....  57C 

Tests  for  motor  power  of  stomach 573 

Tests  for  absorptive  power  of  stomach 579 

Dietetic  treatment  of  dyspepsia  .  .  .  * 579 

Beverages 581 

General  rules  for  dyspeptics 583 

Rules  for  special  varieties  of  dyspepsia 584 

Dyspepsia  in  infants  and  children .  585 

Acute  gastritis 586 

Acute  gastritis  in  infants  and  children  . 588 

Chronic  gastric  catarrh 589 

Chronic  gastric  catarrh  in  children .  596 

Dilatation  of  the  stomach. —  Gastrectasia 596 

Lavage 598 

Massage .  602 

Electricity 602 

Vomiting 603 

Seasickness 605 

Vomiting  of  pregnancy 607 

Ulcer  of  the  stomach 607 

Cancer  of  the  stomach 611 

DIET   IN   DISEASES   OF   THE   INTESTINES 

Diarrhoea 613 

Diarrhoea  in  infants  and  young  children 614 

Examination  of  infant  stools 816 

Entero-colitis  in  infants  and  children.     Summer  diarrhoea         .        .        .617 

Cholera  infantum  or  acute  milk  infection 619 

Cholera  morbus.     Acute  catarrhal  enteritis  in  adults 620 

Intestinal  autointoxication 621 

Chronic  enteritis  in  adults.     Chronic  intestinal  catarrh.     Chronic  colitis  625 

Chronic  intestinal  indigestion  in  children 626 

Chronic   gastrointestinal    catarrh.     Chronic    entero-colitis.     Chronic    diar- 
rhoea in  children 627 

Simple  atrophy.     Marasmus 629 

Mucous    disease.      Chronic    pseudo-membranous    gastro-enteritis.      Mem- 
branous  enteritis 630 

Dysentery 631 

Acute  intestinal   obstruction 632 

Chronic  constipation 633 

Dietetic   treatment 636 

Aids  to  dietetic  treatment 639 

Constipation  in  infants  and  children 641 

Hemorrhoids 643 

Appendicitis 643 

Acute  peritonitis 645 

Chronic  peritonitis 645 


xx  CONTEXTS 

DIET  IN  DISEASES  OF  THE  LIVEB 

PAGE 

Diet  in  liver  diseases  in  general 646 

"Biliousness" 646 

Acute  catarrhal  inflammation  of  the  gall  ducts.     Angiocholitis.     Catar- 

rhal  jaundice 649 

Cirrhosis 650 

Ascites *. 651 

Dietetic  treatment  of  cirrhosis  with  ascites 651 

Fatty  liver 652 

Amyloid  liver 654 

Syphilis  of  the  liver 654 

Abscess  of  the  liver 654 

Gallstones 654 

Diet  in  pancreatic  diseases 657 

DIET  IN   DISEASES   OF   THE   NERVOUS   SYSTEM 

Neuralgia 658 

Visceral   neuralgias 660 

Gastralgia 661 

Enteralgia 662 

Hepatalgia 662 

Migraine 662 

Neurasthenia 664 

The   "  rest   cure  " 667 

Insomnia  and  disordered  sleep 672 

Vertigo 673 

Chorea _  673 

Epilepsy 674 

Beri-beri _  676 

Locomotor  ataxia 676 

Apoplexy  677 

Acute  insanity.     Melancholia.     Primary  dementia.     Mania  ....  678 

Sin-alimentation f  681 

DIET   IN   SKIN   DISEASES 

Skin  diseases  which  are  caused  by  improper  diet     .        .  .   682 

Erythema.     Urticaria >   684 


Acne 


685 


Eczema       ...............  685 

Eczema  in  nursing  infants         ......  688 

Eczema  in   children      ......  089 

Exfoliative  dermatitis      ....... 


.        .        .        .    689 

...........   690 

...........   690 


Eurunculosis       . 


DISEASES    ESPECIALLY   INFLUENCED   BY   DIET 

Ol>o>ity    (Polvsarcia)        .... 
Dietetic    treatment 


694 


CONTENTS  xxi 

PAGE 

Banting , 697 

Ebstein 697 

Oertel 699 

Schweninger 702 

Weir  Mitchell 703 

Yeo 703 

Dujardin-Beaumetz 704 

Von  Noorden 705 

Bouchard 705 

Chambers 706 

Debove 707 

"Anti-fat"  remedies 710 

Diet  for  leanness 710 

Rheumatism,    acute 712 

Chronic 714 

Arthritis  deformans 714 

Gout 715 

Diet  for  the  gouty  diathesis  and  chronic  gout 721 

Beverages 725 

Diabetes  mellitus 729 

Causation 729 

Physiological   experiments 731 

The  pancreas  and  diabetes 733 

Various  theories 734 

Symptoms 735 

Dietetic  treatment 740 

Foods  allowed 744 

Foods   forbidden 747 

Substitutes  for  bread 747 

Substitutes  for  sugar 753 

Beverages 754 

Special    diets 755 

Ebstein's 755 

Diiring's 756 

Naunyn's 757 

Von  Noorden's 757 

Diabetic  coma 758 

Rhachitis    (rickets) 759 

Scurvy 763 

Hsemorrhagic  purpura 767 

DIET   IX   MISCELLANEOUS   DISEASES 

Addison's  disease 767 

Osteomalacia 768 

Exophthalmic  goitre 768 

Chronic  lead  poisoning 769 

Dietetic  difficulties  arising  from  associated  diseases                ....  770 


CONTENTS 

DIET  FOB   SURGICAL  PATIENTS 

PAGE 

Food  and  anaesthetics 772 

Diet  after  anesthesia 772 

Surgical  operations  and  injuries 773 

Laparotomy.     Ovariotomy 775 

Surgical  inflammation.     Sepsis 775 

PART  IX 

RATIONS. — DIETARIES 

Prescribing  dietaries.     Thompson's  diet  lists 777 

Army  and  navy  diets 779 

The  U.  S.  army  rations 779 

Foreign  army  rations 786 

U.  S.  navy  rations 790 

Diet  in  prisons 792 

U.  S.  army  prison  diet 793 

New  York  State  Reformatory  diet 795 

Dietetic  cures 795 

Skimmed  milk  cure 795 

Whey  cure 801 

Koumiss  cure 802 

Various   "  cures  " 803 

Kneipp   system 804 

Fruit  cures 804 

Grape  cure 805 

Meat  and  hot-water  cure 806 

Dry  cure 807 

Purin  free  diet 808 

Diet  in  athletic  training 809 

Dietary  of  the  Yale  boat  crew 811 

Dietary  of  the  Harvard  boat  crew 812 

Dietary  of  the  Yale  football  team 815 

Diet  of  pugilists,  bicycle  riders,  and  jockeys 815 

Diet   and  occupation t  817 

Brain   workers 819 

Commercial  life 823 

Travel 824 

Diet  in  pregnancy 825 

Diet  for  puerperal  women 826 

Selection  of  a  wet  nurse 828  • 

Diet  of  a  nursing  mother  or  wet  nurse 829 

Drugs  in  human  milk 830 

Feeding  of  infants 830 

Overfeeding     ...  831 

Methods  of  feeding  ....  832 

Feeding  by  the  mother  or  wet  nurse 832 

Feeding  by  the  bottle          . 833 

Mixed  feeding „ 337 

Gavago .837 


CONTENTS  -xxin 

PAGE 

Weaning      ... 837 

Artificial  infant  foods      . 840 

Infant  stools 842 

Nursing  bottles 843 

Care  of  infant's  mouth 844 

Weighing  of  infants 844 

Premature   infants 844 

Food  for  young  children 845 

Rules  for  feeding  young  children 847 

Dietaries  for  young  children 848 

Teething  and  food 853 

Sleep  and  feeding 853 

Diet  for  school  children 854 

Diet  and  puberty 855 

Hospital  dietaries 861 

New  York  Hospital 864 

Bellevue,  Gouverneur,  Fordham,  and  Harlem  Hospitals      ....  866 

Presbyterian    Hospital 868 

Roosevelt   Hospital 872 

Johns  Hopkins  Hospital 873 

Cook  County  Hospital 873 

New  York  Infirmary 874 

New  York  State  Hospital 875 

Utica  State  Hospital  for  Insane .  876 

Dietary  for  Liverpool  Infirmary   . 878 

Children's  dietaries  in  English  hospitals 878 

Dietaries  of  army  hospitals 880 

United   States 880 

British 884 

Prussian,  French 885 

APPENDIX 

Receipts   for   invalid   food   and  beverages   suitable   for   fevers  and   conva- 
lescence from  acute  illness 887 

Beverages 887 

Demulcent  and  nutritive 887 

Diuretic  and  refrigerant 889 

Fluid  beef  preparations 889 

Broths  and  soups 891 

Solid  meat  preparations 893 

Milk   preparations 894 

Egg  preparations 897 

Farinaceous    foods 898 

Milk-sugar  preparations 903 

Gelatin  preparations 904 

Fat  foods    ......  906 

Concentrated  fluid  nourishment 906 

Substitutes  for  tea  and  coffee 906 

General  rules  for  prescribing  a  dietary  906 

INDEX  .   909 


LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

1.  General  View  of  the  Respiration  Calorimeter  Laboratory  at  Wesleyan 

University 10 

2.  Interior    of    Respiration    Chamber .      .  11 

3.  Diagram  of  Percentage  Composition  of  Common  Foods.      .  15 

4.  Proportion  of  the  Component  Parts  of  Milk     ....  54 

5.  A  Drop  of  Milk  Magnified,  Showing  Fat  Globules     ...            .      .  54 

6.  Chapman's  Dipper  for  Removing  the  Upper  Layers  of  Milk           .      .  56 

TA.  Human    Colostrum 62 

TB.  Woman's  Milk  at  a  Late  Period 62 

8.  Lactometer        65 

9.  Holt's  Apparatus  for  Examination  of  Woman's  Milk     .....  67 

10.  Creamometer 67 

11.  Tubes  Used  for  Determining  the  Fat  in  Milk 68 

12.  The  Babcock  Cream-Testing  Apparatus 69 

13.  The  Babcock  Cream-Testing  Apparatus 69 

14.  Modern  Milking  Pails  to  Prevent  Access  of  Dirt 78 

• 

15.  Bottling  Room  in  a  High-Class  City  Dairy 80 

16.  The    Arnold    Sterilizer 97 

17.  Sterilization  Oven  Used  in  Bottling  Milk  Under  Steam  Pressure     .  98 

18.  A  Modern  High-Class  Pasteurizing  Plant 101 

19.  Freeman's    Pasteurizer 102 

20.  Centrifugal     Machine 110 

21.  Parts  of  Centrifuge:    Bottles Ill 

22.  Diagram  of  a  Hen's  Egg  Showing  the  Proportion  of  Ingredients     .      .  121 

A  Piece  of  Beef  Magnified 126 

Beef  Fibers  Highly  Magnified 126 

25.  Section  Through   Wheat  Kernel 162 

26.  Cross  Section  of  a  Grain  of  Wheat  as  Seen  Under  the  Microscope  163 

27.  Microscopic  Characters  of  Wheat 164 

28.  Yeast    Plant  —  Torula    cerevisise  —  Magnified 165 

29.  Bread  Made  From  Different  Kinds  of  Flour 170 

30.  Bread  Made  From  Entire  Wheat,  Patent,  and  Graham  Flours,  and 

Character   of  "Feces    From    Same .  172 

31.  Section  of  Grain  of  Corn .182 

32.  Kernels  of  Corn:   High  Oil  and  Low  Oil           183 

XXV 


xxvi  ILLUSTRATIONS 

FIGURE  PAGE 

33.  Kernels  of  Corn:  High  Protein  and  Low  Protein 183 

34.  Lentil 195 

35.  Peanut 196 

36.  Diagram  of  a  Potato,  Showing  Proportion  of  Ingredients     .      .      .   197 

37.  Potato  Starch  as  it  Appears  Under  the  Microscope 198 

38.  Composition   of   Apple 214 

39.  Composition  of  Banana 217 

40.  Composition  of  Dried  Fig 223 

41.  Branches  of  Tea 247 

42.  Branches  of  Coffee 252 

43.  Approximate  Quantity,  in  Grams,  of  Different  Classes  'of  Foods  Con- 

sumed in  Twenty-four  Hours,  Computed  According  to  Age     .      .   329 

44.  Apparatus   for  Drying  Feces  Over  Water   Bath 402 

45.  Diagram  of  the  Relative  Proportion  of  Carbohydrate  in  Foods  Al- 

lowed   Diabetics .    745 


PRACTICAL   DIETETICS 


PART  I 
FOODS  AND  FOOD  PREPARATIONS 


ELEMENTARY  COMPOSITION  OF  FOODS 

OF  the  eighty-two  chemical  elements,  thirteen  enter  uniformly  into 
the  composition  of  the  human  body  and  ten  more  are  occasionally 
found.  Of  all  these,  several  exist  in  very  small  proportion  and  their 
uses  are  unknown;  several  are  present  more  abundantly  but  are  not 
indispensable  to  life,  and  four  elements  —  namely,  carbon,  hydrogen, 
oxygen,  and  nitrogen  —  are  necessary  ingredients  of  all  the  tissues  of 
the  body. 

All  food  is  composed  of  combinations  of  the  simpler  chemical  ele- 
ments which  must  be  subjected  to  alteration  in  the  body  itself  to  pre- 
pare it  for  assimilation  by  the  tissues.  The  nutrition  of  the  body, 
therefore,  involves  four  distinct  processes,  viz. : 

1.  The  secretion  of  digestive  fluids  and  their  action  upon  food  in 
the  alimentary  canal. 

2.  The  absorption  of  the  ingredients  of  the  food  when  digested 
into  the  blood  vessels  and  lymphatic  vessels. 

3.  The   assimilation  of  the  absorbed  nutritious  products  by  the 
tissues. 

4.  The  elimination  of  the  waste  material. 

The  following  analysis  exhibits  the  relative  proportion  of  the 
elements  of  which  the  human  body  is  composed : 

Approximate  Chemical  Analysis  of  a,  Man   (Moss). 
(Height,  5  feet  8  inches;   weight,  148  pounds.) 

Oxygen    92.4  pounds. 

Hvdrogen    14.6 

Carbon     31.6 

Nitrogen    4.6 

Phosphorus     1.4 

Calcium     2.8 

Sulphur  0.24 

Chlorine    0.12 

3  1 


FOODS   AXD   FOOD   PREPARATIONS 

Sodium    0.12  pounds. 

Iron    0.02 

Potassium   0.34 

Magnesium  0.04 

Fluorine    0.02 


Total    148.00  pounds. 

All  these  elements  are  necessarily  derived  from  food  and  water 
phis  the  oxygen  of  the  air  which  is  breathed. 

The  three  predominating  elements  —  oxygen,  hydrogen,  and  car- 
bon—  are  the  great  force  producers  of  the  body,  although  they  are 
tissue  formers  as  well,  and  to  them  must  be  added  nitrogen,  as  serv- 
ing in  this  double  capacity,  although  its  relation  to  tissue  formation 
and  renewal  is  greater  than  its  capacity  for  supplying  energy. 

According  to  the  experiments  of  Benedict  and  Milner,  the  weight 
of  oxygen  taken  into  the  body  in  24  hours  at  rest  is  0.39  gram, 
and  at  work  0.86  gram  per  hour  per  kilo  of  body  weight.  Hence 
the  amount  of  oxygen  consumed  is  proportionate  to  muscular  work. 
The  weight  of  C02  eliminated  at  rest  is  0.47  gram,  and  at  work  1.01 
gram.  That  of  water  is  for  rest  0.49  gram,  for  work  2.15  gram  per 
kilo  of  body  weight.  In  general  the  output  of  hydrogen  is  parallel 
with  that  of  carbon. 

The  common  elements  which  enter  into  tissue  formation  chiefly 
and  which  bear  no  direct  relation  to  the  main  sources  of  energy  in 
the  body  are  chlorine,  sulphur,  phosphorus,  iron,  sodium,  potassium, 
calcium,  and  magnesium  in  different  combinations.  Bone  tissue,  for 
example,  contains  about  50  per  cent  of  calcium  phosphate.  If  this 
substance  is  deficient  in  the  food  of  the  young  growing  infant,  the 
bones  are  poorly  developed  and  so  soft  that  they  yield  to  the  strain  of 
the  weight  of  the  body  and  become  bent,  as  occurs  in  rickets. 

Lack  of  iron  salts  in  the  food  impoverishes  the  coloring  matter 
of  the  red  blood-corpuscles  on  which  they  depend  for  their  power  of 
carrying  oxygon  to  the  tissues,  and  anaemia  and  other  disorders  of 
deficient  oxidation  result. 

Lack  of  sufficient  potash  salts,  especially  potassium  carbonate  and 
chloride,  is  a  factor  in  producing  scurvy,  and  the  condition  is  intensi- 
fied by  the  excessive  use  of  common  salt. 

Lack  of  sodium  chloride  interferes  with  many  of  the  functions  of 
the  body  immediately  concerned  with  nutrition,  such  as  absorption, 
secretion,  etc.,  and  alters  the  density  and  reactions  of  the  different 
body  fluids. 

Tbes.<-  few  illustrations  suggest  the  diversity  of  roles  exhibited  by 
the  elements  and  the  need  for  a  correctly  balanced  diet. 


ELEMENTARY   COMPOSITION   OF  FOODS  3 

In  order  to  determine  what  such  a  diet  should  consist  of  it  is  neces- 
sary to  study  the  value  of  the  principal  classes  of  foods  in  force  pro- 
duction and  in  nutrient  power  or  "  tissue  building,"  but  before  pro- 
ceeding further  with  this  discussion  it  will  be  advisable  to  adopt  a 
simple  comprehensive  classification  of  the  foods  in  general  use  by  man. 

The  following  table  of  analyses  made  by  Dujardin-Beaumetz  shows 
the  proportion  of  nitrogen  present  in  different  foods,  and  also  the 
combustible  carbon  and  hydrogen. 

("  The  hydrogen  existing  in  the  compound  in  excess  of  what  is  re- 
quired to  form  water  with  the  oxygen  present  is  calculated  as 
carbon.") 


Nitrogen. 


C  +  H. 

Combustibles 

calculated  as 

carbon. 


Beef    (uncooked)    3.00 

Roast   beef    3.53 

Calf's  liver    3.09 

Foie-gras    2.12 

Cod,  salted    5  02 

Herring,  salted  3.11 

Whiting   2.41 

Mackerel 3.74 

Sole  1.91 

Salmon  2.09 

Oysters   2.13 

Lobster    ( uncooked ) 2.93 

Eggs 1.90 

Milk    (cow's)    0.66 

Cheese    (Brie)     2.93 

Cheese   (Gruyere)    • 5.00 

Chocolate   1.52 

Rye  flour   1.75 

Winter   barley    1.90 

Maize    1.70 

Buckwheat  2.20 

Rice 1.80 

Oatmeal   , 1.95 

Bread,  white  (Paris,  thirty  per  cent,  water) 1.08 

Bread,  brown    (soldiers'  rations)     1.20 

Potatoes   0.33 

Beans     4.50 

Peas   (dry)    3.66 

Carrots   0.31 

Mushrooms    0.60 

Figs    (dry)    0.92 

Plums 0.75 

Coffee   (infusion  of  100  grammes)    1.10 

Tea    (infusion  of  100  grammes)    1.00 

Bacon    1-29 

Butter  (fresh )    0.64 

Olive  oil    Trace 

Beer,  strong    0.05 

Wine  .                         0.15 


11.00 
17.76 
15.68 
65.58 
16.00 
23.00 

9.00 
19.26 
12.25 
16.00 

7.18 
10.96 
13.50 

8.00 
35.00 
38.00 
58.00 
41.00 
40.00 
44.00 
42.50 
41.00 
44.00 
29.50 
30.00 
11.00 
42.00 
44.00 

5.50 

4.52 
34.00 
28.00 

9.00 
10.50 
71.14 
83.00 
98.00 

4.50 

4.00 


4  FOODS  AND  FOOD  PREPARATIONS 

To  estimate  the  equivalent  chemical  elements  in  the  different  food 
classes  the  following  standards  are  adopted : 

1.  To  obtain  the  amount  of  nitrogen  in  proteid  foods,  divide  the 
quantity  of  food  by  the  factor  6.5. 

2.  To  obtain  the  carbon  in  fat,  multiply  the  quantity  of  fat  by 
0.765. 

3.  To  obtain  the  carbon  in  carbohydrate  food,  multiply  by  0.444. 

4.  To  obtain  the  carbon  in  proteid  food,  multiply  by  0.535. 

Estimates  vary  somewhat  as  to  the  average  quantity  of  the  ele- 
ments carbon  and  nitrogen  consumed  per  diem.  In  a  general  way  it 
may  be  said  that  the  consumption  of  carbon  is  320  grams  (10  ozs.). 
and  that  of  nitrogen  about  20  grams  (308  grains.)  (See  tables,  pp. 
27,  28.) 

FOOD  CLASSIFICATION 

Foods  may  be  classed  in  various  ways,  according  to — (1)  Their 
physical  properties.  (2)  Their  source.  (3)  Their  composition. 
(4)  The  role  which  they  perform  in  the  animal  body. 

1.  Physical  Properties. —  Foods  are  classed  in  accordance  with  their 
general  physical  properties:     First,  into  solid,  semisolid,  and  liquid 
foods;  secondly,  into  fibrous,  gelatinous,  starchy  or  amylaceous,  ole- 
aginous, crystalline,  and  albuminous  foods. 

A  subdivision  sometimes  used  is  that  of  the  "  complete "  foods, 
such  as  eggs  or  milk,  which  in  a  single  article  comprise  all  the  neces- 
sary elements  to  support  life,  and  "  incomplete "  foods,  which  are 
capable  of  maintaining  life  only  for  a  comparatively  short  time. 

2.  Source. —  Foods  may  be  classed  as  to  their  source  primarily  into 
(a)  animal  and  (b)  vegetable  foods. 

(a)  Animal  foods  consist  of  meats,  fowl,  fish,  shellfish,  crustaceans, 
insects  and  their  products  (e.  g.  honey),  eggs,  milk  and  its  products, 
animal  fats,  gelatin. 

(b)  Vegetable  foods  are  subdivided  into  cereals,  vegetables  proper, 
fruits,  sugars,  gums  and  vegetable  oils  and  fats. 

3.  Composition. —  The  simplest  chemical  classification  possible  is 
that  advocated  by  Baron  von  Liebig,  who  was  the  first  to  suggest  a 
really  scientific  division  of  foods.     He  grouped  all   foods  into  two 
classes  — 

a.  Xitroofenons.     I.  Xon-nitrogenous. 

Each  of  these  classes  contains  food  materials  derived  from  both 
the  animal  and  vegetable  kingdoms,  although  the  majority  of  the 
animal  substances  belong  to  the  nitrogenous,  and  the  majority  of 
vegetable  substances  to  the  non-nitrogenous  group. 


FOOD   CLASSIFICATION  5 

a.  The  nitrogenous  group  von  Liebig  regarded  as  containing 
"  plastic  "  elements  —  i.  e.,  they  are  essentially  "  tissue  builders  "  or 
"  flesh  formers." 

Nitrogenous  foods  are  called  proteids  and  include  gelatinoids  and 
albuminoids  —  that  is,  substances  resembling  albumin.  They  con- 
sist chiefly  of  the  four  elements  carbon,  oxygen,  hydrogen,  and  nitro- 
gen, to  which  a  small  proportion  of  sulphur  and  phosphorus  are  usually 
joined.  These  elements  for  the  most  part  are  combined  as  some  form 
of  albumin. 

Nitrogenous  or  proteid  foods  are  non-crystallizable,  but  coagula- 
ble,  fluid,  solid  or  semisolid  substances.  They  are  fermentable,  and 
under  some  conditions  will  putrefy,  both  within  and  without  the  ali- 
mentary canal. 

The  nitrogenous  group  comprises  all  forms  of  animal  food,  except- 
ing fats,  glycogen,  and  such  substances  as  milk-sugar  and  honey.  Its 
chief  representatives  are  milk,  eggs,  crustaceans,  fish,  shellfish,  flesh, 
and  fowl.  It  also  contains  such  nitrogenous  substances  as  exist  in  the 
vegetable  kingdom  or  "  vegetable  albuminoids,"  notably  in  peas  and 
beans. 

&.  The  non-nitrogenous  group  von  Liebig  called  "  respiratory  or 
calorifacient  foods,"  because  their  function  in  the  body  is  to  furnish 
fuel  to  maintain  animal  heat.  Since  this  original  classification  was 
suggested  it  has  been  established  that  the  non-nitrogenous  aliments 
supply  energy  for  muscular  action,  hence  they  are  also  called  "  force 
producers,"  in  distinction  from  the  nitrogenous  or  proteid  "  tissue 
builders." 

This  is  a  convenient  distinction  to  adopt,  but  it  must  not  be  held 
too  absolutely,  for  in  emergencies  the  tissue  builders  are  used  as  force 
and  heat  producers  as  well. 

The  non-nitrogenous  group  consists  chiefly  of  combinations  of  the 
three  elements  carbon,  hydrogen,  and  oxygen,  although  various  salts 
are  mixed  with  both  vegetable  and  animal  foods.  It  includes  vegeta- 
bles, fruits,  cereals,  starches,  sugars,  gums,  fats  and  oils  (which  latter 
are  both  animal  and  vegetable),  and  organic  acids.  Many  vegetables 
and  cereals,  besides  some  fruits,  contain  considerable  nitrogen,  but  the 
"  carbohydrates  " —  i.  e.,  starches  and  sugars  —  constitute  their  main 
bulk. 

Neither  is  animal  food  strictly  nitrogenous,  on  account  of  its  fat 
and  glycogen,  nor  is  vegetable  food  strictly  non-nitrogenous,  owing 
to  its  albuminoids  and  other  forms  of  proteids,  yet  this  classification 
is  a  very  convenient  and  simple  one  which  has  met  with  general  ac- 
ceptance. It  will  be  used  in  this  book  whenever  a  further  degree  of 


6  FOODS   AND   FOOD   PREPARATIONS 

subdivision  is  not  needed,  but  always  with  the  understanding  that  it 
has  a  not  too  literal  application,  and,  unless  otherwise  distinctly 
specified,  "  nitrogenous  or  proteid  food  "  will  be  understood  to  include 
animal  foods  and  "  non-nitrogenous  food  "  to  include  vegetable  foods 
of  all  kinds. 

For  the  purpose  of  the  present  work,  it  is  convenient  to  subdivide 
foods  by  the  following  classification:  I.  Water;  II.  Salts;  III. 
Proteids ;  IV.  Starches ;  V.  Sugars ;  VI.  Fats  and  oils. 

Protein  is  a  comprehensive  term  used  in  food  calculations  to  sig- 
nify all  nitrogenous  food  substances.  Proteids  are  nitrogenous  sub- 
stances of  definite  composition  forming  a  portion  of  the  protein  class, 
such  as  egg  albumen,  meat  albumin,  etc. 

Some  writers  class  oxygen  in  a  separate  division  among  foods. 
This  seems  unnecessary,  unless  a  separate  division  is  made  for  hydro- 
gen, and  in  fact  for  each  element.  The  primary  object  of  food  classi- 
fication is  to  obtain  a  practical  working  basis  of  subdivision,  and  the 
less  complex  this  is  made,  the  better. 

FORCE  PRODUCTION.  ENERGY  FROM  FOOD 

The  two  ultimate  uses  of  all  food  are  to  supply  the  body  with 
materials  for  growth  or  renewal,  and  with  energy  or  the  capacity  for 
doing  work.  The  energy  received  in  a  latent  form,  stored  in  the 
various  chemical  combinations  of  foods,  is  liberated  as  kinetic  or 
active  energy  in  two  chief  forms:  first,  as  heat;  second,  as  motion. 
Force  is  the  manifestation  of  energy.  The  force  developed  by  a 
healthy  man  may  be  measured  in  foot  pounds,  a  foot  pound  being  the 
amount  of  energy  expended  or  force  required  to  mechanically  lift  a 
weight  of  one  pound  through  a  height  of  one  foot. 

The  work  of  the  average  man  is  calculated  to  be  about  2,000,000 
foot  pounds  per  diem  (E.  H.  Thurston).  This  may  exceptionally 
be  increased  to  3,000,000  foot  pounds.  According  to  the  study  of 
1».  ('.  Carpenter  of  a  phenomenal  athlete  named  Miller,  the  latter 
developed  work  amounting  to  over  15,000,000  foot  pounds  (7,500 
foot  tons)  on  the  first  day  of  a  six-days'  bicycle  contest,  and  5,500,000 
foot  pounds  (2,750  foot  tons)  on  the  last  day. 

A  man  weighing  one  hundred  and  fifty  pounds  —  or  nearly  one 
thirteenth  of  a  ton  —  obviously  expends  considerable  energy  in  merely 
moving  his  own  body  about  from  place  to  place,  aside  from  carrying 
any  additional  burden.  Ordinarily  less  than  one-fifth  of  the  total 
energy  of  the  body  is  expended  in  motion  and  more  than  four-fifths 
in  heat  production. 


FORCE   PRODUCTION.      ENERGY   FROM   FOOD  7 

The  total  intake  of  energy  of  the  body  is  derived  from  foods  plus 
the  oxygen  of  the  inspired  air.  The  total  output  of  energy  is  com- 
puted from  (1)  the  heat  of  combustion  of  the  unoxidized  ingredients 
of  the  urine  and  feces,  (2)  the  energy  liberated  as  body  heat,  and 
(3)  the  energy  of  external  muscular  work,  or  the  work  of  the  vol- 
untary muscles. 

A  useful  comparison  may  be  made  between  the  processes  of  nutri- 
tion and  development  of  energy  from  food  in  the  human  body  and 
the  energy  derived  from  a  steam  engine  and  boiler.  In  both  cases  the 
main  source  of  energy  is  oxidation,  and  principally  of  carbon.  In 
both  cases  the  latent  energy  of  the  carbon  liberated  by  oxidation  proc- 
esses is  converted  into  heat  and  motion,  forms  of  energy  which  bear 
a  definite  relation  to  one  another.  If  a  large  part  of  the  original 
latent  energy  is  converted  into  heat,  there  is  less  to  yield  motion,  and 
conversely. 

In  the  athlete  Miller  above  referred  to,  Carpenter  found  that  the 
energy  developed  lr  this  man  equaled  45  per  cent  of  the  total  heat 
of  combustion  calculated  for  his  food.  Carpenter  says :  "  The  best 
record  of  any  heat  engine  is  probably  that  of  the  Deisal  motor,  which 
devolops  33.7  per  cent  of  the  heat  energy  of  its  fuel,  and  the  best  record 
of  a  steam  engine  is  that  of  the  Nordberg  pumping  engine  at  Pitts- 
burg,  which  develops  22.7  per  cent  of  energy." 

"  From  this  comparison  it  would  seem  that  the  human  machine  is 
decidedly  superior  to  any  heat  engine  which  has  been  developed  in 
form  so  as  to  be  of  any  value  for  practical  use." 

Finally,  after  combustion  of  the  carbon  by  the  fires  of  the  boiler  a 
certain  amount  of  waste  matter  or  ash  is  produced.  If  this  is  allowed 
to  accumulate,  it  obstructs  the  draught  and  interferes  with  active 
oxidation.  In  the  human  body,  in  like  manner,  the  fuel  or  food  con- 
sumed produces  ashes,  such  as  urea  and  other  forms  of  waste  material, 
which,  if  not  removed,  accumulate  in  the  system  and  embarrass  or 
retard  the  normal  oxidation  processes.  The  body  possesses  the  addi- 
tional power  of  modifying  and  distributing  the  fuel  food  which  it 
receives  so  as  to  develop  its  energy  to  the  best  advantage  in  different 
organs.  The  heat  eliminated  per  hour  per  kilo  (2%  Ibs.)  of  body 
weight  averages  1.48  calories  or  heat  units  for  a  man  at  rest,  2.83  for 
moderate  exercise  and  4.12  for  arduous  work. 

Whether  alimentary  substances  are  burned  outside  of  the  body  or 
oxidized  within  the  body,  the  resulting  waste  products  are  similar. 
There  can  be  no  loss  of  matter,  and  there  can  be  no  loss  of  energy. 
The  matter  is  simply  changed  in  form  by  molecTilar  rearrangement, 
the  energy  is  converted  from  one  type  into  another.  The  following 


8  FOODS   AND   FOOD   PREPARATIONS 

simple  experiment  will  illustrate  this  point :  In  a  large  covered  glass 
jar  place  an  ounce  of  alcohol  in  a  small  metal  vessel.  Also  place  in 
the  jar  a  little  lime  water  in  a  tumbler,  and  a  thermometer.  On 
igniting  the  alcohol  and  allowing  it  to  burn  away  completely,  a  film 
of  aqueous  vapor  will  accumulate  on  the  surface  of  the  jar,  and  a 
film  of  calcium  carbonate  will  form  on  the  surface  of  the  lime  water 
produced  by  the  union  of  carbonic-acid  gas  with  the  lime  water. 
The  thermometer  will  indicate  a  rise  in  temperature  of  the  air  in  the 
jar.  An  ounce  of  alcohol  consumed  as  food  will  similarly  be  con- 
verted into  carbonic-acid  gas  and  water,  and  in  this  process  the  body 
heat  will  be  increased.  By  blowing  expired  air  through  a  glass  tube 
into  a  tumbler  containing  lime  water,  the  presence  of  carbonic 
acid  is  made  apparent  by  the  resulting  turbidity  of  the  lime  water. 
No  substance  is  a  good  food  unless  it  fulfills  two  conditions  —  viz., 
easy  assimilation  and  complete  combustion.  The  proportion  of  any 
given  food  actually  assimilated  (i.  e.,  not  rejected  in  the  feces)  is 
called  its  "  coefficient  of  digestibility." 

Metabolism  within  the  body  is  not  alone  controlled  by  muscular 
work,  but  by  the  nervous  energy  expended  in  its  performance. 

The  relative  importance  of  the  different  food  fuels  should  be  con- 
sidered. This  is  well  summarized  by  Major  Charles  E.  Woodruff, 
U.  S.  A. : 

"  For  instance,  cut  off  the  supply  of  oxygen,  and  death  ensues  in 
from  one  to  ten  minutes.  If  water  is  witheld,  preventing  the  trans- 
portation of  the  fuel  and  oxygen  to  various  part  of  the  body,  death 
follows  in  about  two  to  seven  days  or  more,  according  to  climate, 
exposure  and  exercise.  If  the  fuel  itself  is  taken  away,  death  follows 
in  from  seven  to  forty  days  or  more,  according  to  the  amount  of 
exposure  that  would  abstract  heat  and  the  amount  of  work  that 
would  use  up  the  energy  already  stored  up  in  the  body.  If  materials 
for  the  repair  of  tissues  be  excluded,  death  follows  in  a  variable  time, 
dependent  upon  the  importance  of  the  tissue  that  is  being  starved." 

The  energy  derived  from  fats  and  from  carbohydrates  as  sources  of 
muscular  work  and  as  "  tissue  sparers  "  or  protectors  of  the  body  ma- 
terial is  almost  equal  (fats  being  very  slightly  inferior  as  sources  of 
muscular  work),  but  fats  furnish  energy  in  the  form  of  heat  in  a 
proportion  %y±  times  greater  than  carbohydrates.  Pfliiger  and 
Argutinsky  still  hold  the  older  view  that  protein  is  the  chief  source 
of  muscular  work,  but  this  is  certainly  not  the  case  on  a  mixed  diet, 
with  which  the  energy  of  protein  oxidized  is  less  than  that  of  work 
performed.  Benedict  and  Milner,  as  well  as  -most  physiologists,  are 
agreed  upon  the  latter  view. 


FORCE  PRODUCTION.      ENERGY  FROM  FOOD  9 

Two  methods  may  be  employed  to  study  the  energy-producing  power 
of  food  in  the  body.  First.  The  protracted  study  of  subjects  who  are 
allowed  to  follow  their  usual  avocations,  but  whose  food  and  excreta 
are  carefully  measured  and  analyzed  through  a  period  of  weeks  or 
months.  This  method  (detailed  on  pages  20,  21)  has  yielded  much 
valuable  information,  but  is  liable  to  errors  arising  from  uncontrolla- 
ble circumstances,  such  as  an  attack  of  influenza  or  of  indigestion,  or 
worry,  fatigue,  or  disgust  with  the  monotony  of  a  diet,  or  the  influence 
of  the  subject's  attention  directed  to  his  symptoms  or  his  food.  More- 
over, there  is  the  difficulty  of  always  collecting  the  excreta,  and  the  la- 
bor and  expense  of  prolonged  daily  analyses.  Second.  The  second  is 
the  shorter  method  of  enclosing  a  man  for  a  brief  period,  not  exceeding 
a  few  days,  in  a  cabinet  known  as  a  "  calorimeter  "  where  extremely 
accurate  and  comprehensive,  but  necessarily  brief  studies  are  made. 
This  method  yields  certain  very  interesting  results,  but  is  open  to  the 
objection  that  the  subject  is  not  living  under  normal  conditions  of 
life,  as  to  occupation,  locomotion,  etc.  In  other  words,  it  is  a  highly 
artificial  method  and  does  not  admit  of  the  study  of  diet  in  disease, 
as  well  as  the  former  process.  By  either  method,  uniformity  of  the 
subject's  conditions  and  diet  is  secured  as  nearly  as  possible  through- 
out the  experiment,  and  to  save  unnecessary  repetition  of  food  analysis, 
certain  standard  rations  may  be  analyzed  once  for  all.  Thus  canned 
vegetables  are  of  fairly  uniform  composition  for  the  same  lot  of  cans 
purchased,  bread  is  made  from  the  same  sample  of  flour  throughout, 
potatoes  are  used  of  uniform  size,  meat  and  fish  may  be  ground  in  a 
sausage  grinder  and  analyzed  either  fresh  or  dried,  eggs  and  pudding 
may  be  analyzed  in  a  mixed  standard  sample,  and  seasoning  is  added 
only  at  table  in  measured  quantity,  etc. 

The  Calorimeter. —  There  are  several  types  of  calorimeter  in  which 
several  thousand  experiments  have  been  made  upon  man.  The  most 
elaborate  and  ingenious  apparatus  of  this  sort  is  the  "respiration 
calorimeter"  constructed  at  Wesley  an  University  by  Profs.  W.  0. 
Atwater  and  E.  B.  Eosa.  It  consists  of  a  chamber  seven  feet  long, 
six  feet  four  inches  high,  and  four  feet  wide,  in  which  a  man  may 
remain  day  and  night,  being  supplied  with  fresh  air  and  food.  The 
chamber  is  practically  a  many-walled,  air-tight  box  having  air  spaces 
between  the  walls  which  are  so  constructed  as  to  maintain  a  uniform 
temperature  within  and  prevent  all  external  temperature  changes  from 
affecting  the  interior.  There  are  two  inner  metal  walls  composed 
respectively  of  copper  and  zinc,  and  three  outer  wooden  walls  rein- 
forced by  thick  builders'  paper.  Between  these  five  walls,  which  com- 
pletely surround  the  box,  over  top  and  bottom  as  well  as  sides,  are 
4 


10 


FOODS  AXD  FOOD  PREPARATIONS 


m 

'-5  M) 


sri'-s 

CM  a;  C 

O  -*  E 

H  3  ^2 

•<!  O  oc 


S5 


a. 


FORCE  PRODUCTION.      ENERGY  PROM   FOOD  11 

four  air  spaces  several  inches  in  thickness,  two  containing  dead  air 
and  two  circulating  air,  kept  in  motion  by  electric  fans  and  warmed 
or  cooled  according  to  need,  so  as  to  maintain  a  constant  temperature 
within.  A  glass -window  constructed  with  successive  layers  like  the 
walls  serves  to  admit  the  man  under  observation,  after  which  it  is 


FIG.  2. —  INTERIOR  OF  RESPIRATION  CHAMBER. 

View  taken  from  the  window. 
(U.  S.  Dept.  of  Agri.,  Bui.  175,  Office  of  Expt.  Stations.) 

hermetically  soldered.  A  small  air  lock  is  used  to  admit  food  and  to 
pass  out  excrement  for  analysis.  The  chamber  contains  a  folding 
bed,  table  and  chair,  a  pair  of  scales,  telephone  and  a  stationary  bicycle 
which  operates  a  small  dynamo  and  electric  light.  The  heat  from 
the  light  is  computed,  together  with  that  dissipated  from  the  man's 
body  within  the  chamber,  and  this  gives  a  measure  of  muscular  work 
converted  into  the  energy  of  heat.  The  heat  is  conveyed  away  from 


12          FOODS  AND  FOOD  PREPARATIONS 

the  chamber  by  means  of  a  current  of  cold  water  passing  through 
copper  pipes,  and  is  measured  by  electric  thermometers.  Circulating 
air  is  supplied  to  the  interior  of  the  chamber,  and  samples  are  with- 
drawn for  analysis  as  it  enters  and  leaves  the  chamber.  In  this  man- 
ner is  measured  the  quantity  of  C02  and  water  eliminated  through 
the  lungs  and  skin.  The  volume  and  temperature  of  the  air  is  care- 
fully regulated.  The  man  who  is  the  subject  of  experimentation  is 
put  upon  a  measured  diet  for  four  days  before  entering  the  calori- 
meter in  order  to  establish  "  nitrogenous  equilibrium  "  and  record  ob- 
servations upon  the  food,  excrement,  amount  of  work  performed,  etc. 
He  then  enters  the  calorimeter,  where  he  remains  four  days  and  five 
nights.  In  the  "  rest  experiments  "  the  subject  makes  as  little  mus- 
cular exertion  as  possible,  but  in  the  "  work  experiments  "  he  operates 
the  stationary  bicycle  for  eight  hours  a  day.  The  delicacy  of  the 
apparatus  is  shown  by  the  fact  that  in  the  thermo-electric  measure- 
ment system  304  pairs  of  metallic  junctions  are  distributed  through- 
out the  inner  wall  air  space,  and  the  heat  generated,  by  such  slight 
movements  as  turning  in  bed  or  rising  from  a  chair  at  once  produces 
a  deflection  of  the  thermal  galvanometer.  This  calorimeter  has  lately 
been  improved  by  F.  G.  Benedict  and  E.  D.  Milner,  so  as  to  permit 
of  direct  measurement  of  the  quantity  of  oxygen  consumed,  in  relation 
to  food  katabolism,  and  they  have  demonstrated  that  oxygen  con- 
sumption is  considerably  influenced  by  the  nature  of  the  diet. 

The  main  value  of  the  experiments  thus  far  conducted  in  this 
calorimeter  consists  in  the  actual  demonstration  that  the  law  of  the 
conservation  of  energy  operates  within  the  body  in  precisely  the  same 
manner  that  it  does  outside.  In  man  it  was  found  that  the  meas- 
ured energy  of  the  food  consumed  by  the  subject  within  the  calori- 
meter was  within  99  per  cent  of  the  calculated  or  theoretical  energy. 
A  margin  of  1  per  cent  of  error  is  certainly  very  small  in  view  of 
the  difficulties  of  such  complicated  experiments.  It  is  possible  that 
some  of  the  energy  may  be  stored  permanently  within  the  body,  and 
another  physiological  source  of  slight  error  lies  in  possible  differences 
in  temperature  of  the  whole  body  between  entering  and  leaving  the 
calorimeter.  The  other  important  use  of  the  respiration  calorimeter 
is  to  determine  the  fuel  value  of  different  foods,  alcohol,  etc.,  in  fur- 
nishing heat  and  motion  for  the  body.  The  complete  calorimeter 
experiment  comprises :  ( 1 )  weighing  and  analysis  of  food,  f eces,  and 
urine;  (2)  determination  of  the  C02  and  water  eliminated  by  the 
patient;  (3)  estimation  of  the  oxygen  consumed;  (4)  estimation  of 
the  energy  produced  by  the  body  in  the  form  of  heat,  both  when  at 
rest  and  in  motion,  the  motion  being  converted  into  heat,  by  means 


FORCE   PRODUCTION.      ENERGY   FROM   FOOD 


13 


of  the  bicycle,  dynamo  and  electric  light  above  described.  The  re- 
sults obtained  by  Professor  Atwater  in  two  of  his  calorimeter  experi- 
ments are  tabulated  by  him  as  follows: 

Comparison  of  Daily  Income  and  Outgo  of  Protein  and  of  Energy  in  the  Rest 
and  Work  Experiments    (Nos.  9  and  6). 


EXPERIMENT. 

PROTEIN. 

ENERGY. 

Of   food. 

Actually 
oxidised. 

Of  food, 

Of 

material 
actually 
oxidised. 

Measured. 

Difference 
in  per  cent 
of  heat  of 
material 
actually 
oxidised 

Rest    (No.    9)  
Work   (No.  6)  .... 

Grams. 

119.4 
119.4 

Grams. 
115.0 
103.1 

Calories. 
2,717 
3,678 

Calories. 

2,275 
3,830 

Calories. 

2,310 
3,726 

Per  cent. 

+  1.5 
—  2.7 

Average  Daily  Income  and  Outgo  of  Nitrogen  and  Carbon  in  the  Rest  and 
Work  Experiments  (Nos.  9  and  6),  with  the  Estimated  Gain  or  Loss 
of  Protein  and  of  Fat. 


NITROGEN. 

CARBON 

CALCULATED 

GAIN  OR  LOSS. 

EXPERIMENT. 

Gain 

In  re 

Gain 

In 

food. 

In 
feces. 

In 
urine. 

(+)or 
loss 

In 
food. 

In 
feces. 

In 
urine. 

tory 
prod- 

(+)or 
loss 
/      1 

Of  pro- 
tein. 

Of  fat. 

ucts. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Gms. 

Rest    (No.  9). 

19.1 

1.2 

18.4 

—0.6 

261.5 

13.3 

12.6 

223.6 

+12.0 

—3.6 

+18.2 

Work  (No.  6). 

19.1 

1.5 

16.5 

+1.1 

336.7 

12.4 

12.5 

345.2 

-33.3 

+69 

—48.3 

An  ingenious  device  was  used  to  differentiate  the  feces  belonging 
to  the  period  of  experimentation  before  entering  the  calorimeter  from 
those  following  ingestion  of  food  within  the  apparatus.  To  do  this, 
before  entering  the  calorimeter  the  man  is  required  to  take  a  few  grains 
of  lampblack  in  a  gelatin  capsule  with  his  food.  This  harmless  sub- 
stance colors  the  stool  and  marks  the  dividing  line  between  any  sub- 
stances already  present  in  the  intestine,  and  food  subsequently  in- 
troduced. 

The  unit  of  measurement  used  in  calorimeter  experiments  is  the 
"  calorie/'  which  is  the  amount  of  heat  required  to  raise  1  kilogram 
of  water  from  0°  to  1°  C. ;  this  equals  3,100  foot  pounds,  or,  ap- 
proximately, is  the  heat  required  to  raise  the  temperature  of  one  pound 
of  water  4°  F.  Fuel  value  is  a  term  denoting  the  total  calories  deriv- 
able from  a  pound  of  any  given  food  substance  if  it  be  completely  com- 
busted within  the  body.  The  fuel  values  are  calculated  for  a  given 
food  by  the  -factors  of  Eiibner  as  follows :  4.1  calories  per  gram  of 
either  ^protein  or  carbohydrate,  and  9.3  calories  per  gram  of  fat. 
This  corresponds  with  18.6  calories  of  energy  for  each  hundredth  of 


14  FOODS  AND  FOOD  PREPARATIONS 

a  pound  of  protein  or  carbohydrate  and  42.2  calories  for  the  same 
quantity  of  fat  in  any  food.  Atwater  and  Bryant  compute  the  food 
factors  as  4  calories  per  gram  for  proteids  and  for  carbohydrates  and 
8.9  per  gram  for  fats  in  a  mixed  diet.  As  stated  by  C.  F.  Lang- 
worthy,  the  fuel  value  of  the  three  chief  classes  of  nutrients  is  as 
follows : 

One  pound  of  protein  yields    1,860  calories. 

"  fats  "        4,220 

"         "         "  carbohydrates     1,860 

"  In  other  words,  when  we  compare  the  nutrients  in  respect  to 
their  fuel  values,  their  capacities  for  yielding  heat  and  mechanical 
power,  a  pound  of  protein  of  lean  meat  or  albumin  of  egg  is  just 
about  equivalent  to  a  pound  of  sugar  or  starch,  and  a  little  over  two 
pounds  of  either  would  be  required  to  equal  a  pound  of  the  fat  of 
meat  or  butter  or  the  body  fat,"  or  as  stated  by  A.  C.  True :  "  The 
fuel  value  of  a  pound  of  protein  as  it  is  ordinarily  burned  in  the 
body  is  very  nearly  the  same  as  that  of  a  pound  of  carbohydrates, 
but  fats  have  a  fuel  value  of  two  and  one  quarter  times  that  of 
protein  and  carbohydrates,  or  4,220  calories  per  pound." 

Elaborate  investigations  have  been  made  with  all  the  principal 
classes  of  foods  in  order  to  estimate  their  nutrient,  their  heat-pro- 
ducing, and  their  force-producing  value,  and  many  statistical  tables 
have  been  compiled.  It  should  be  remembered  that  all  this  work 
is  approximate,  and  that  the  liability  to  error  in  the  various  factors 
is  considerable,  but  in  a  general  way  the  results  are  instructive,  and 
they  are  certainly  interesting  and  not  without  practical  application. 
A  day  laborer  requires  0.28  pound  of  protein  per  diem  plus  enough 
fat  and  carbohydrate  to  yield  a  total  fuel  value  of  3,500  calories. 
A  professional  man  requires  0.22  to  0.25  pound  of  protein  to  yield 
2,700  to  3,000  calories  of  energy,  but  more  than  that  is  often  con- 
sumed. Study  at  the  Storrs  Experiment  Station  in  Connecticut  of 
nine  families  of  professional  men  showed  an  actual  consumption  of 
107  grains  of  protein,  and  a  diet  fuel  value  of  3,430  calories.  The 
standard  for  a  man  at  light  muscular  labor  demands  112  grams  (3*A 
DZS.)  of  protein  and  a  fuel  value  of  3,000  calories. 

The  mere  calculation  of  the  nitrogen  and  carbon  in  a  food  does 
not  at  all  show  its  force  value  in  the  body,  unless  at  the  same  time  it 
may  bo  demonstrated  that  it  is  assimilable.  Wood  pulp  may  be  made 
to  furnish  cellulose  and  yield  much  energy,  but  it  is  worse  than 
useless  in  the  stomach  of  man,  although  some  of  the  lower  animals, 
like  rodents,  can  digest  it  and  make  it  available  for  nutrition.  Sugar 
may  he  made  from  old  rags  in  the  laboratory,  yet  no  stomach  can  deal 
with  such  material. 


FORCE   PRODUCTION.      ENERGY   FROM   FOOD 


15 


Tables  are  now  available  for  the  calculation  of  the  force  value  of 
rations  for  large  bodies  of  men  under  different  conditions,  as,  for 
example,  soldiers  in  barracks  or  on  the  march,  which  are  based  upon 
the  principle  of  careful  comparisons  between  the  income  and  output 
of  energy  of  the  body.  The  force-producing  value  of  different  classes 
of  foods,  as  obtained  by  chemical  research,  is  carefully  compared  with 
the  amount  of  waste  matter  which  is  eliminated  by  the  system  while 
a  man  is  being  fed  upon  a  measured  quantity  of  food  and  kept  under 
uniform  conditions  as  regards  the  amount  of  work  performed.  In 


CANNED  TOMATOES. ..I 


MILK. 


BEEF.. 


J 


BACON. 


BEANS. 


FLOUR. 


BUTTER 


OATMEAL 


I       I  WATER  IIS  PROTEIhlBB  FAT       ^Hl  CARBOHYDRATE 
FIG.  3. —  DIAGRAM  OF  PERCENTAGE  COMPOSITION  OF  COMMON  FOODS. 

this  manner  a  check  is  established  upon  the  theoretical  calculations 
of  food  values  as  compared  with  their  practical  uses  in  maintaining 
the  equilibrium  of  nutrition.  A  diet  system  to  which  a  man  may  be 
willing  to  submit  for  a  few  weeks  or  even  months  is  by  no  means 
always  that  which  will  prove  best  for  him  through  a  longer  period, 
and  a  too  rigid  application  of  the  rules  established  for  the  computa- 
tion of  the  force  value  of  foods  yields  much  less  practical  results 
than  the  experience  derived  by  those  who  actually  control  the  com- 
missary department  with  due  regard  to  proper  economy  and  variation 
in  food,  but  without  resort  to  calculations  of  grams  of  carbon,  nitro- 
gen, etc. 

A  criticism  reached  me  from  the  inmates  of  a  large  girls'  college, 


16 


FOODS  AND  FOOD  PREPARATIONS 


where  the  diet  was  for  some  time  experimentally  regulated  by  an 
expert  in  such  matters,  that  "  if  one-half  the  time  were  bestowed 
upon  properly  serving  and  selecting  the  food  that  is  given  to  com- 
putation of  its  force-producing  value,  the  girls  would  have  very  much 
better  appetites  and  digestion."  On  the  other  hand,  it  is  easy  to 
err  if  the  dictates  of  hunger  and  capriciousness  of  appetite  are  al- 
lowed wholly  to  control  diet. 

With  this  word  of  explanation  the  following  tables  from  different 
authors  are  reproduced.  It  will  be  observed  that  there  are  some 
few  discrepancies  among  them,  but  the  cause  has  been  explained 
above. 

The  following  table  of  analyses  is  given  by  Major  Charles  E. 
Woodruff,  Surgeon,  United  States  Army: 

Percentage  Composition  of  Edible  Portions  of  Garrison  Ration. 


Water. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Salts. 

Energy, 
calories 
per  Ib. 

Bacon,  fat   

20.0 

8  00 

69.5 

2.5 

3,080 

Beans        

12.6 

23  10 

2  0 

59.2 

3  1 

1615 

Pork,  salt  and  fat  .... 

12.1 

0.90 

82.8 

4.2 

3,510 

Sugar,     ground    

2.0 

97.8 

0.2 

1,820 

Sugar,  brown  issue  .  .  . 

3.0 

96.5 

0.5 

1,795 

Flour                  

12  5 

11  00 

1  0 

74  9 

0  5 

1  644 

Beef    .  .      .            

55  0 

17  10 

27  0 

0  9 

1  460 

Potatoes       .      .  .        ... 

78  9 

2  10 

0  1 

17  9 

1  0 

375 

Onions    

87  6 

1  4 

0  3 

10  1 

0  6 

225 

Oatmeal    

7.6 

15  10 

7  1 

68  2 

2  0 

1,850 

Cornmeal   

15  0 

9  20 

3  8 

70  6 

1  4 

1  645 

Canned  apples  

83.2 

0  20 

0  4 

15.9 

0.3 

315 

Dried  apples   

25.0 

0  90 

1.8 

71.5 

1  4 

1,418 

Tapioca  or  cornstarch  . 
Butter    

2.0 
10.5 

i  oo 

85  6 

97.8 
0  5 

0.2 
3  0 

1,820 
3,615 

Sirup    

43  7 

55  0 

2  3 

1,023 

Lard    

12  0 

0  60 

83  4 

4  0 

3,570 

Rice    

12  4 

7  4 

0  4 

79  4 

0  4 

1,630 

Canned  corn   

81  3 

2  80 

1  1 

13  2 

0  6 

345 

Canned  tomatoes    

96.0 

0  82 

0.4 

2.5 

0.3 

80 

Macaroni  and  vermicelli. 
Milk,  fresh    

13.1 

88  0 

9.00 
3  0 

0.3 
3  3 

76.8 
5  0 

0.8 
0  1 

1,406 
325 

Milk,  condensed    

25.0 

17  00 

11  0 

44  00 

3  0 

1,595 

Peas                

12  3 

26  70 

1  7 

56  40 

2  9 

1  565 

Raisins     

40  0 

0  40 

24  00 

0  6 

440 

Cheese      

35  0 

33  00 

22  0 

5  00 

5  0 

1  600 

Prunes    

30  0 

2  50 

12  0 

0  6 

140 

Cabbage            .          .... 

92  0 

2  10 

0  6 

5  5 

1  i 

IfSR 

Ham    

41  5 

16  7 

39  1 

2  7 

1  960 

Apricots,  canned    .  .    .  . 

50  0 

2  00 

30  0 

0  fi 

460 

Barley    

13  00 

2  7 

76  0 

3  0 

1  800 

Chocolate     

12  0 

20  00 

50  0 

10  0 

4  0 

2  650 

Sausage    
Oysters     

41.2 

87  1 

13.80 
6  00 

42.8 
1  2 

37 

2.2 
2  0 

2,065 
230 

Salmon,  canned  

63  6 

21  60 

13  4 

1  4 

965 

Crabs    

15  0 

1  0 

526 

Crackers     .  .      ... 

10.3 

9.4 

70.5 

1,900 

FORCE   PRODUCTION.      ENERGY   FROM   FOOD 


17 


Standards  for  Daily  Dietaries. 

(Compiled  by  Atwater.) 

Weights   of   nutrients  and   calories  of  energy   in   nutrients   required   in   food 

per  day. 


NUTRIENTS. 

Poten- 
tial 
energy 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total 

1.  Children  up  to  a  year  and  a  half.  . 
2.  Children  of  two  to  six  years  

Grtns. 
28 
(20-36) 
55 
(36-70) 
75 
(70-80) 
80 
100 
92 
118 
145 

119 
156 

185 

80 
100 
125 
150 

130 
120 

Grms. 

37 

(30-45) 
40 
(35-48) 
43 
(37-50) 
50 
68 
44 
56 
100 

51 
71 

71 

80 
100 
125 
150 

40 
35 

Grins. 
75 
(60-90) 
200 
(100-250) 
325 
(250-400) 
260 
350 
400 
500 
450 

531 

568 
568 

300 
360 
450 
500 

550 
540 

Grms. 

140 
295 
443 

390 
518 
536 
674 
695 

701 

795 
824 

460 
460 
700 
800 

720 
695 

Calories 

767 
1,418 
2,041 

1,859 
2,477 
2,426 
3,055 
3,370 

3,139 
3,629 
3,748 

2,300 
2,820 
3,520 
4,060 

3,160 
3,032 

3.  Children  of  six  to  fifteen  years  .... 
4.  Aged   woman  

5.  Aged  man  

6.  Woman  at  moderate  work   (Voit)  . 
7.  Man  at  moderate  work    (Voit)  .  .  . 
8.  Man  at  hard  work    (Voit)  

9.  Man  with  moderate  exercise   (Play- 
fair)     

10.  Active  labor    (  Playfair  )  

11.  Hard  labor   (Playfair)  

12.  Woman    with    light    exercise    (At- 
water)     

13.  Man  with  light  exercise  (Atwater) 
14.  Man  at  moderate  work-  (Atwater)  . 
15.  Man  at  hard  work  (Atwater)  

16.  Man     at     moderate     work      (Mole- 
schott)    

17.  Man  at  moderate  work   (Wolff)  .  .  . 

Landois  and  Stirling  give  the  following  table,  which  differs  some- 
what from  other  estimates  in  the  relative  proportion  of  fats  and 
starches.  An  adult  doing  a  moderate  amount  of  work  takes  in  as 
food  per  diem  — 


* 

Carbon. 

Hydrogen. 

Nitrogen. 

Oxygen. 

120 
90 

grams  albumin,  containing... 
"       fats,   containing  

64.18 
70.20 

8.60 
10.26 

18.88 

28.34 
9.54 

330 

"       starches,   containing.  .  . 

146.82 

20.33 

162.85 

Grams. 

281.20 

39.19 

18.88 

200.73 

Add    744.11      grams     0.  from  the  air  by  respiration. 
"  2,818.00  H,0. 

"        32.00          "          inorganic  compounds    (salts). 

The  whole  is  equal  to  three  kilograms  and  a  half  (seven  pounds), 
i.  e.,  about  a  twentieth  of  the  body  weight,  so  that  about  6  per  cent 
of  the  water,  6  per  cent  of  the  fat,  1  per  cent  of  the  albumin,  and 


18 


FOODS  AND  FOOD  PREPARATIONS 


0.4  per  cent  of  the  salts  of  the  body  are  daily  transformed  or  re- 
placed within  the  organism. 

An  adult  doing  a  moderate  amount  of  work  eliminates  in  grams: 


Water. 

C. 

H. 

N. 

0. 

330 

248.8. 

? 

651.15 

660 

2.6 

7.2 

By  urine     

1,700 

9.8 

3.3 

is.  8 

11.1 

By  feces    

128 

20.0 

3.0 

3.0 

12.0 

2,818 

281.2 

6.3 

18.8 

681.45 

The  following  table  represents  a  fair  average  work  ration  in  round 
numbers,  based  on  such  data  as  those  in  the  foregoing  tables : 

Estimated  Work  Ration,  Maximum  and  Minimum. 

(Mrs.   E.  H.  Richards.)  For  one  day. 

(  125 
Proteid,  grams   M 1 0 

(  125 

/    90 

(450 
J420 
(3,500 
j  3,000 


Fat,  grams 

Carbohydrates,  grams 


About  thirty  grams  of  salts  should  be  added  to  this. 
subsistence  ration  is  much  less,  as  follows: 


The  bare 


Estimated  Minimum  Ration  to  Barely  Sustain  Life. 

(Mrs.   E.   H.   Richards.)  For  one  day. 

Proteid,  grams   ...........................................         75 

Fat,  grams  ...............................................        40 

Carbohydrates,  grams    .....................................       325  . 

Calories,    (total)    .........................................   2,000 

An  Ideal  Ration  with  Solid  Food. 
(Mrs.  E.  H.  Richards.) 


MATERIAL. 

AMOUNT. 

PROTEID. 

FATS. 

CARBOHYDRATES. 

Calories. 

Grms. 

Oz. 

Grnis. 

Oz. 

Grms. 

Oz. 

Grms. 

Oz. 

Bread      

253.6 

226.8 
226.8 
28.3 
113.4 
453.6 
28.3 
14.17 

16 

8 
8 
1 
4 
16 
1 
i 

31.75 
34.02 
12.52 
6.60 
3.63 
18.14 

1.12 
1  20 
0.44 
0.23 
0.13 
0  64 

2.26 
11.34 
2.04 
7.50 
4.42 
18.14 

0.08 
0.40 
0.07 
0.26 
0.16 
0.64 

257.28 

9.04 

1,206.82 
243.72 
70.01 
135.42 
75.55 
613.21 
112.17 
118.62 

Meat 

Breakfast    cocoa  . 
Milk 

9.60 
4.88 
90.72 
27.36 

0.34 
0.17 
3.20 
0.96 

Broth 

Suirar 

Butter 

0.14 

12.27 

Total... 

- 

106.80 

57.97 

389.84 

2,575.52 

FORCE  PRODUCING  VALUE  OF  FOODS         19 

It  will  be  observed  that  the  totals  are  somewhat  less  in  this  diet 
than  those  of  the  table  above  given,  which  was  adapted  for  a  work- 
ing man,  who  is  developing  more  calories. 

FORCE-PRODUCING  VALUE  OF  THE  DIFFERENT 
CLASSES  OF  FOODS 

I.  Water. —  Estimated  as  a  force  producer  within  the  body,  water 
may  be  said  to  have  little  or  no  value.     Much  of  the  water  which 
is  either  drunk  or  ingested  in  combination  with  foods  passes  through 
the  body  unchanged,  and  is  eliminated  from  one  or  more  of  the  ex- 
creting surfaces;  but  some  of  it  is  undoubtedly  altered  or  split  up 
into  elements  which  unite  with  other  compounds.     The  nature  of 
these  processes  is  obscure,  and  as  yet  very  little  understood.     It  is 
believed  also  that  a  certain  quantity  of  water  is  produced  in  the  body 
by  the  union  of  oxygen  and  hydrogen  which  occurs  incident  to  other 
chemical  change,  or  by  the  liberation  of  water  from  more  complex 
molecules.     Water  is  entitled  to  rank  as  a  food  because  it  enters 
into  the  structural  composition  of  all  the  tissues  of  the  body,  and, 
in  fact,  constitutes  rather  more  than  two-thirds    (70  per  cent)   of 
the  entire  body  weight. 

Yeo  says  that  we  may  assume  the  water-free  food  to  equal  23 
ounces.  Ordinary  solid  food  contains  usually  between  50  and  60  per 
cent  of  water;  if  we  add  this  to  the  water-free  solids,  the  total 
daily  amount  of  so-called  "dry"  food  (exclusive  of  liquids)  is  about 
48  to  60  ounces.  But  from  50  to  80  ounces  of  water  in  liquid 
form  is  usually  drunk  in  addition,  and  this  would  make  the  total 
supply  of  water  equal  70  to  90  ounces,  or  half  an  ounce  for  each 
pound  of  body  weight. 

II.  Salts. —  The  salts  are  concerned  in  tissue  formation,  especially 
in  the  bones  and  teeth,  where  the  lime  and  magnesium  compounds 
are  the  most  stable  of  any  in  the  body.     Some  of  the  compounds  of 
sulphur  and  phosphorus  which  exist  in  meat  and  bran  are  undoubt- 
edly associated  with  the  development  of  energy  in  the  body,  but  the 
salts  are  already  saturated  and  relatively  stable,  and,  although  their 
functions  as  reagents  within  the  body  are  numerous,  they  may  be 
left  out  of  calculations  of  force-producing  foods. 

III.  Proteids,  Carbohydrates,  and  Fats. —  The  relation  of  proteids 
to  muscular  work  depends  to  a  great  extent  upon  the  quantity  of 
carbohydrates   and  fats   simultaneously  supplied  in  the   diet  —  thus 
W.   0.   Atwater  and  H.   C.   Sherman  state    (U.    S.   Department   of 
Agriculture,  Bulletin  No.  98)  that: 


20          FOODS  AND  FOOD  PREPARATIONS 

"  Practically  all  of  the  recent  experimenting  with  men  sustains  the 
view  that  muscular  work  normally  results  in  an  increased  excretion 
of  nitrogen  when  the  work  is  at  all  severe  and  there  is  not  a  cor- 
responding increase  in  the  fuel  ingredients  (fats  or  carbohydrates)  of 
the  diet.  It  also  implies  that  the  increased  output  of  nitrogen  con- 
tinues after  the  work  stops,  so  that  if  the  experiment  continues  but 
one  day  the  larger  part  of  the  increase  may  be  found  on  the  succeed- 
ing day. 

"  Well-trained  professional  athletes  when  engaged  in  severe  mus- 
cular exertion  metabolize  relatively  large  amounts  of  protein,  the 
body  tissue  being  drawn  upon  unless  the  protein  of  the  food  is  very 
abundant. 

An  interesting  series  of  experiments  was  made  upon  sixteen  persons 
by  Prof.  Charles  E.  Waite,  of  the  University  of  Tennessee  (TJ.  S.  De- 
partment of  Agriculture  Bulletin  No.  89).  The  experiments  in- 
cluded rest  intervals  followed  by  work  periods,  usually  of  about  four 
hours  per  diem.  Waite  found  that  the  digestibility  of  the  diet  was 
uninfluenced  by  moderate  work,  animal  protein  being  more  completely 
digested  than  vegetable  protein.  He  concludes  as  follows : 

"A  study  of  the  nitrogen  balance  shows  that  in  the  majority  of 
cases  if  there  was  a  gain  during  the  rest  period  it  was  increased  dur- 
ing the  work  period,  and  if  there  was  a  loss  it  was  diminished.  In 
other  words,  comparing  the  elimination  of  nitrogen  in  the  urine 
during  the  periods  of  little  muscular  activity  and  normal  diet  with 
that  during  periods  of  increased  activity  and  a  diet  furnishing  energy 
largely  in  excess  of  the  heat  equivalent  of  the  measured  work  per- 
formed, there  seems  to  be  a  slight  decrease  under  the  latter  condition. 
This  is  true  even  when  we  consider  the  possibilities  of  a  small  loss 
of  nitrogen  in  the  perspiration  and  a  lag  of  considerable  duration 
between  the  breaking  down  of  nitrogenous  material  within  the  body 
and  the  excretion  of  nitrogen  in  the  urine." 

The  standard  diet  for  twenty-four  hours  for  a  healthy  adult  male 
at  ordinary  work  should  contain,  in  round  numbers,  20  grams  of 
nitrogen  (contained  in  120  grams  of  proteid)  and  320  grams  of 
carbon,  or  for  a  man  of  average  weight  —  that  is,  67  kilograms,  or 
160  pounds  —  the  daily  allowance  of  food  ranges  from  6  to  9  grams 
of  carbon,  and  0.2.5  to  0.36  gram  of  nitrogen  per  kilogram  of  body 
weight.  Those  elementary  foods  which  approach  most  nearly  .in  com- 
position the  economical  proportion  of  nitrogenous  to  non-nitrogenous 
material  are  cow's  milk  and  wheat  flour.  In  the  former  this  propor- 
tion is  one  to  three,  in  the  latter  one  to  four  and  a  half.  The 
standard  ratio  for  health  of  protein  to  the  fuel  or  heat  producing 


21 

ingredients  —  starch,  sugar,  and  fat  —  is  1  to  5.8.  This  is  the  ratio 
adopted  by  the  Experiment  Stations  of  the  United  States  Depart- 
ment of  Agriculture  —  in  round  numbers  therefore,  1  part  by  weight 
if  animal  to  6  parts  of  vegetable  or  non-nitrogenous  food  should 
be  eaten. 

The  proportion  of  nitrogenous  or  proteid  compounds  required  is 
greatest  where  growth  is  active.  Many  nitrogenous  substances  pos- 
sess high  potential  and  explosive  energy,  as  illustrated  by  nitro- 
glycerin  and  fulminating  powder.  Proteids  are  always  present  where 
the  phenomena  of  life  are  exhibited,  and  bear  a  direct  relation  to 
their  activity. 

-Nitrogen  Balance  and  Nitrogen  Lag. — The  nitrogen  in  the  urine  and 
feces  may  be  regarded  as  an  index  of  the  proteid  food  assimilated, 
and  when  these  two  factors  correspond,  the  body  is  said  to  be-  in 
"  nitrogen  equilibrium,"  i.  e.,  all  the  nitrogen  actually  consumed  is 
eliminated  without  storage  in  the  body.  When  the  body  has  attained 
its  full  adult  size,  it  maintains  this  equilibrium  with  but  very  slight 
variation.  A  diet  containing  either  an  excess  or  diminution  of  protein 
temporarily  disturbs  this  equilibrium,  but  it  is  soon  readjusted. 

For  an  adult  male  the  average  consumption  of  nitrogen  being  20 
grams  per  diem,  the  ordinary  allowance  for  daily  variation  does  not 
exceed  3  grams  on  either  side  of  this  standard. 

In  metabolism  experiments  a  time  allowance  must  be  made  for 
the  interval  between  the  ingestion  of  proteid  food  and  the  corres- 
ponding nitrogen  increase  in  urine  and  feces.  This  interval  is 
known  as  the  "  nitrogen  lag,"  and  it  occupies  a  number  of  hours,  or 
several  days,  varying  under  changing  conditions.  In  most  cases, 
however,  the  nitrogen  of  proteid  food  is  excreted  within  24  hours. 
In  general,  the  balance  of  sulphur  and  phosphorus  keeps  pace  with  that 
of  nitrogen  and  in  the  equilibrium  of  health  the  quantities  of  these 
elements  excreted  (mainly  in  the  urine)  should  closely  balance  the 
quantities  ingested. 

The  role  of  the  carbohydrates  and  fats  is  to  supply  body  heat,  and 
also  to  a  considerable  extent  muscle  energy,  and  to  "spare  the  tissues 
from  destructive  katabolism  during  increased  work.  Fats,  compared 
with  carbohydrates,  yield  two  and  one-fourth  parts  as  much  heat 
energy. 

The  question  of  the  nutritive  value  of  any  fixed  diet  cannot  be 
estimated  solely  from  variations  in  the  body  weight,  for  the  loss  of 
water  or  of  albumin  may  increase  while  fat  is  stored  up.  Neither 
may  the  quantity  of  food  eaten  be  relied  upon  for  this  purpose,  for 
from  habit  one  man  may  eat  more  than  another  while  doing  the  same 


FOODS   AND   FOOD   PREPARATIONS 

work,  and  may  eat  more  than  he  needs.  Nor  is  it  possible  to 
determine  from  the  various  excreta  alone  whether  the  body  has  had 
a  suitable  quantit^y  of  nourishment.  Hence  scientifically  complete 
studies  of  food  energy  should  include  all  the  factors,  viz.,  (1)  the 
quantity  and  quality  of  food  ingested  (2)  and  of  the  excreta  elim- 
inated, (3)  gain  or  loss  in  body  weight  and  (4)  the  amount  of  work 
performed. 

A  man  in  perfect  health  might  easily  lose  weight  upon  the  identical 
diet  which  would  enable  an  emaciated  and  feeble  invalid  to  gain 
flesh.  In  convalescence  from  typhoid  fever,  for  example,  one  often 
sees  evidence  of  a  daily  gain  in  weight  while  the  quantity  of  food  is 
still  far  below  that  necessary  to  support  a  healthy  man  in  vigor. 
The  needs  of  the  organism  at  any  particular  time  should,  therefore,  be 
taken  into  account  as  well  as  the  strength  of  the  digestive  organs  in 
prescribing  the  quantity  of  food  consumed.  In  making  calculations 
for  the  quantity  of  food  required  by  large  numbers  of  persons  under 
any  conditions,  somewhat  more  than  the  averages  above  stated  should 
be  included  always  in  order  to  make  allowance  for  variations  in  ab- 
sorption and  assimilation  of  the  food  by  different  individuals.  (See 
tables,  pp.  27,  28.) 

Bauer  says :  "  The  action  of  the  carbohydrates  agrees  in  many 
respects  with  that  of  fat,  since  they  are  in  like  manner  capable  of 
protecting  from  metabolism  a  certain  amount  of  the  circulating  al- 
bumin and  of  assisting  its  transformation  into  organic  albumin." 

But  the  katabolism  of  carbohydrates  in  the  body  is  very  com- 
plete, even  when  eaten  in  excess,  and  herein  they  differ  from  the 
fats,  "  an  excess  of  which  in  the  food  invariably  produces  an  ac- 
cession of  fat."  From  these  and  other  statements  made  by  Bauer 
lie  argues  that  probably  the  carbohydrates  do  not  directly  form  fat  in 
the  body,  but  their  well-known  fattening  action  is,  when  eaten  with 
albumin  and  fat,  to  spare  the  consumption  of  these  latter  substances, 
which  are  then  converted  into  tissue  fat. 

Sugars  furnish,  in  addition  to  heat,  considerable  muscle  energy, 
and  have  been  proved  lately  by  Mosso,  Vaughan  Harley,  and  others 
to  have  distinct  power  in  relieving  muscular  fatigue. 

Vaughan  Harley  found  that  with  an  exclusive  diet  of  seventeen 
and  one-half  ounces  of  sugar  dissolved  in  water,  he  could  perform 
almost  as  much  muscular  work  as  upon  a  full  mixed  diet.  The  effect 
in  lessening  muscle  fatigue  was  noticeable  in  half  an  hour  and  reached 
a  maximum  in  two  hours.  Three  or  four  ounces  of  sugar  taken  be- 
fore the  expected  onset  of  fatigue  postponed  or  entirely  inhibited 
the  sensation.  Schumberg  recommends  that  the  sugar  be  taken  with 


FORCE  PRODUCING  VALUE  OF  FOODS 

chocolate  or  in  lemonade.  Experiments  were  made  by  him  upon 
German  soldiers  which  covered  a  period  of  thirty-eight  days.  The 
men  were  given  daily  ten  lumps  of  sugar  (about  one-sixth  pound), 
and  were  able  to  withstand  hunger,  thirst,  and  fatigue  much  better 
than  others  whose  diet  contained  no  sugar.  When  a  muscle  con- 
tracts it  is  not  the  muscle  tissue  itself  which  is  consumed,  but  its 
supply  of  glycogen.  The  candle  wick  is  very  slowly  burned  so  long 
as  its  supply  of  tallow  does  not  fail,  and  so  the  muscle  is  spared 
while  the  carbohydrate  glycogen  furnishes  force.  When  a  muscle 
is  much  used  it  increases  in  size,  and  needs  more  nitrogen  to  build 
new  substance. 

The  food  value  of  sugar  is  thus  summarized  by  Mary  Hinman 
Abel: 

"  In  small  quantities  and  in  not  too  concentrated  form  sugar  will 
take  the  place,  practically  speaking,  weight  for  weight,  of  starch  as 
a  food  for  muscular  work,  barring  the  difference  in  energy  and  in 
time  required  to  digest  them,  sugar  having  here  the  advantage. 

"  In  times  of  great  exertion  or  exhausting  labor,  the  rapidity  with 
which  it  is  assimilated  gives  it  certain  advantages  over  starch." 

The  hard-working  lumbermen  of  Canada  and  Maine  eat  a  very 
large  quantity  of  sugar  in  the  form  of  molasses.  I  have  seen  them 
add  it  to  tea  and  to  almost  everything  they  cook.  Sugar  has  also 
been  found  of  much  service  upon  polar  expeditions. 

Albumin  burned  in  oxygen  outside  of  the  body  is  almost  com- 
pletely oxidized,  but  after  oxidation  in  the  body,  about  one-third  of 
its  substance  is  excreted,  imperfectly  consumed,  as  urea.  Pfliiger 
says :  "  All  work  of  life  can  be  performed  by  albumin  alone,  while 
no  other  material  in  the  universe  can  do  it.  The  integral  ingredient 
of  the  living  and  working  cell  is  the  albumin,  indeed  often  the  only 
organic  part  of  it."  On  the  other  hand,  the  consumption  of  some 
carbohydrates,  such  as  alcohol  and  sugar,  appears  as  complete  within 
the  body  as  it  may  be  outside  of  it,  and  the  amount  of  energy  ac- 
tually developed  is  identical  with  that  which  may  be  theoretically 
calculated. 

Following  is  a  useful  diagrammatic  summary  by  Atwater  of  the 
economy  of  food  in  the  system : 

Nutritive  Ingredients  (or  Nutrients)   of  Food. 


Food  as  purchased 
contains  — 


rWater. 

Edible  portion    J  ,  Protein. 

e.  g.,  flesh  of  meat,  volk    Nutrients.       Fats. 


?at,  yolk 
I,  wheat, 


and  white  of  egg,  wheat,  J  Carbohydrates, 

flour,  etc.  |  Mineral       mat- 

Refuse,  ters. 

e.  g.,  bones,  entrails,  shells,  bran,  etc. 


24          FOODS  AND  FOOD  PREPARATIONS 

Uses  of  Nutrients  in  the  Body. 

Protein    Forms  tissue 

e.  g.,  white  (albumen) 
of  egg,  curd  (casein)  of 
milk,  lean  meat,  gluten 


of  wheat,  etc. 

Fats   Are  stored  as  fat . 

e.  g.,  fat  of  meat,  butter, 
olive    oil,    oils    of    corn 


All  serve  as  fuel  to  yield 
energy  in  the  forms  of 
heat  and  muscular 
power. 


and  wheat,  etc. 

Carbohydrates    Are  transformed  into  fat 

e.  g.,  sugar,  starch,  etc. 
Mineral  matters   (ash)    ..Share  in  forming  bone,  assist  in  digestion,  etc. 

e.  g.,  phosphates  of  lime, 

potash,  soda,  etc. 


OXYGEN  AND  FOOD 

The  food  ingested  must  be  oxidized  by  means  of  the  respired  air, 
hence  active  breathing  in  pure  fresh  air  is  essential  for  complete 
metabolism  of  food.  It  is  important  to  determine  the  ratio  of  the 
oxygen  existing  in  food  as  eaten,  to  that  of  the  oxygen  required 
to  reduce  the  food  to  its  ultimate  waste  products.  Careful  study 
of  this  subject  has  been  made  by  Prof.  E.  Maurel  of  Toulouse  (Traite 
de  1' Alimentation  et  de  la  Nutrition,  1908).  He  finds  that  adopting 
a  standard  ration  per  kilogram  (2  1-5  Ibs.)  of  body  weight  this 
ration  contains  in  round  numbers  3  grams  (46  grains)  of  oxygen,  and 
requires  a  further  11  grams  (170  grains)  or  nearly  four  times  as 
much,  to  burn  it  completely  within  the  body.  The  11  grams  of 
oxygen  are  divided  as  follows: 

4.8  grams  to  oxidize  the  4.5  grams  of  carbohydrates 

3.         "  "     1.     gram    of  fat. 

1.         "  "     0.5  gram    of  alcohol. 

3.        "  "     1.5  grams  of  albuminoids. 

The  latter  constitute  the  standard  ration  calculated  per  kilogram 
of  body  weight  per  diem.  The  11  grams  of  oxygen  develop  38 
calories.  lie  estimates  that  the  average  man  requires  7  liters  of 
oxygen  per  kilogram  of  body  weight  per  diem  to  oxidize  his  food 
thoroughly.  Infants,  having  relatively  large  body  surface  in  pro- 
portion to  their  weight,  require  relatively  more  food  and  oxygen. 
Thus  an  infant  weighing  3  or  4  kilograms  requires  14  liters  of 
oxygon  per  kilogram,  but  this  disproportion  rapidly  lessens  with  its 
srowth. 


ECONOMIC   VALUE  OF   FOOD  25 

STIMULATING  FOODS 

In  the  broadest  sense  all  food  is  stimulating  to  the  functional  ac- 
tivities of  the  body;  but  when  the  digestive  and  assimilative  powers 
are  lowered,  less  variety  and  less  quantity  of  food  can  be  tolerated, 
and  foods  that  in  health  are  never  needed  may  become  necessities; 
such  foods,  for  example,  are  cod-liver  oil  and  the  various  prepara- 
tions of  meat,  such  as  albumoses  or  peptones,  meat  juice,  etc. 

Certain  food  substances  have  a  distinctly  stimulating  action  at 
all  times.  The  condiments  and  spices  possess  a  local  action  of  this 
kind  upon  the  alimentary  organs,  but  not  a  general  or  systemic  ac- 
tion. The  latter  stimulation,  manifested  especially  upon  the  nerve- 
muscular  apparatus,  is  derived  from  such  substances  as  strong  beef 
extracts,  coffee,  tea,  sugar  and  alcohol. 

ECONOMIC  VALUE  OF  FOOD 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
the  economic  value  of  food,  but  brief  reference  to  one  or  two  facts 
will  emphasize  the  importance  of  this  topic. 

It  is  estimated  that  the  annual  cost  of  food  production  in  the 
United  States  is  at  least  three  billion  dollars,  and  the  cost  of  pro- 
duction should  be  doubled  in  estimating  the  price  paid  by  the  con- 
sumer. 

It  is  often  important  to  tabulate  the  cost  of  feeding  large  bodies 
of  men  employed  by  contract,  or  patients  in  hospitals  and  institu- 
tions, armies  and  navies,  etc. 

The  economic  value  of  food  cannot  be  estimated  comparatively 
from  its  weight,  for  a  pound  of  biscuit  may  contain  as  much  fuel 
as  a  pound  of  beefsteak,  and  yet  the  body  may  be  able  to  assimilate 
more  of  the  beefsteak  and  derive  more  energy  therefrom. 

Carbohydrates  check  proteid  waste,  and,  like  fats,  yield  both  heat 
and  mechanical  work;  hence  good  bread,  sugar,  and  potatoes  are 
all  economical  foods  for  the  laborer.  Unlike  the  other  classes  of 
foods,  however,  they  do  not  produce  brawn,  and  do  not  enter  into 
the  actual  structure  of  the  tissues  to  any  great  extent,  although  the 
carbohydrates  may  be  found  existing  as  glycogen  in  some  of  the 
tissues,  like  the  muscles  and  liver.  In  general,  they  seem  to  be 
more  easily  metabolized  than  fats  or  proteids.  Assuming  3,500 
calories  as  the  necessary  daily  standard  for  a  laborer,  one  pound 
of  flour  yields  0.11  pound  of  protein  and  1,650  calories;  a  pound  of 
dried  beans  yields  0.22  pound  of  protein  and  1,590  calories;  but  cab- 


bage  yields  only  0.02  protein  and  150  calories  per  pound,  and  oranges 
0.01  protein  and  160  calories. 

Aticater's  Table  of  Digestibility  of  Nutrients  of  Food  Materials. 


IN  THE  FOOD  MATERIALS  BELOW 

OF  THE  TOTAL  AMOUNTS  OF  PROTEIN,  FATS  AND 
CARBOHYDRATES  THE  FOLLOWING    PERCENTAGES 
WERE  DIGESTED. 

Protein. 

Fats. 

Carbohydrates. 

Practically  all 
88  to  100 

79  to  92 
96 
93  to  98 
98 
96 
? 
? 
? 
? 
i> 
? 

'? 

99 
97 
99 
96 
92 
82 

Esrsrs  . 

Milk           

Butter 

Oleomarga  rine 

Wheat   bread          

81  to  100 
89 
84 
86 
74 
72 

Corn  (maize)  meal  

Rice    

Peas                        

Potatoes  

Beets    

Calculated   Coefficients  of  Digestibility   of   Nutrients  in   Different   Classes  of 

Foods. 

Standards  used  in  calculations  by  the  U.  S.  Department  of  Agriculture. 


Protein. 

Fats. 

Carbohydrates. 

Animal  foods    

Per  cent 
OR 

Per  cent. 
Q7 

Per  cent. 

inn 

Cereals  and  starches    

85 

00 

oft 

Susars    . 

100 

Vegetables  and  fruits     

80 

90 

95 

The  actual  cost  of  elementary  foods  naturally  varies  with  the 
market,  locality,  season  of  the  year,  and  other  considerations.  For- 
tunately, however,  many  foods  which  furnish  most  nutriment  are 
among  the  cheapest  and  least  variable  in  price.  Cereals,  for  instance, 
which  readily  may  furnish  one-third  of  the  total  nutrients  re- 
quired, do  not  vary  greatly  in  price.  Hence,  when  it  is  neces- 
sary to  reduce  the  cost  of  living,  peas,  beans,  oatmeal,  and 
flour  may  be  used  economically  to  supply  protein.  Sugar,  rice, 
pork,  cornmeal,  and  potatoes  all  supply  fuel  energy  at  small  expense. 
If  variety  rather  than  cheapness  is  desired,  it  is  found  in  the  use 
of  green  vegetables,  fresh  fruits,  butter,  eggs,  and  the  better  cuts 
of  meat.  Tn  illustration  of  these  principles  are  the  following  tables 
from  nutrition  investigations  conducted  by  Isabel  Bevier  at  Pittsburg, 
V;\.  (V .  S.  Department  of  Agriculture  Bulletin  52)  ; 


ECONOMIC   VALUE   OF   FOOD 


Cost  per  Pound  and  Amounts  and  Fuel  Value  of  the  Digestible  Nutrients  in 
1  Pound  and  in  10  Cents'  Worth  of  the  More  Important  Food  Materials 
used  in  a  Dietary  Study  of  a  very  Poor  Polish  Mill-worker's  Family  in 
Pittsburg,  Pa. 


KIND  OF  FOOD 
MATERIAL. 

Actual 
cost  per 
pound. 

NUTRIENTS  AND    ENERGY  IN  I 
POUND. 

NUTRIENTS  AND  ENERGY  IN 
10  CENTS'  WORTH.    • 

Protein 

Fat. 

Carbohy- 
drates. 

Fuel 
value. 

Pro- 
tein. 

Fats. 

Car- 
bohy- 
drates. 

Fuel, 
value 

Cal. 

1,270 
995 
1,205 

982 
1,555 

2,105 
430 
1,400 
970 
4,385 
3,520 
3,340 
3,010 
2,495 
2,420 

Beef: 
Stew  meat       .... 

Cents. 

5.0 
8.9 
9.4 

18.8 
8.5 

5.9 

14.2 
25.5 
2.8 
3.6 
5.0 
3.4 
5  9 

Pound. 

0.176 
202 
.176 

.178 
.183 

.339 
.126 
.010 
.031 
.096 
.133 
.078 

Pound. 

0.073 
.121 
.191 

.359 
.233 

.145 
.089 
.843 
.025 
.010 
.064 

Pound. 
0.058 

.730 
.669 
.532 
.954 

Cal. 

635 

885 
1,130 

1,845 
1,325 

1,245 
610 
3,575 
270 
1,580 
1,760 
1,135 
1,775 

Lb. 

0.15 
.14 
.20 

.19 
.27 

.25 

.06 
.33 
.09 
.03 
.13 

Lb. 

Pound. 

0.35 
.23 
•    19 

.09 
.21 

.57 
.09 

Bologna    sausage  . 
Pork  : 
Hani   boiled         .  . 

Head-cheese   

Fish,      herring, 
smoked   

Errors 

Butter 

Milk                

0.21 
2.03 
1.33 
1.56 
1  61 

.11 
.27 
.27 
.23 

Flour    

Oatmeal      

Bread      

Beans        

5.8 
1.1 

.178 
.013 

.016 

.561 
.130 

1,442 
265 

.03 

.97 
1.18 

.31 
.12 

Potatoes   

Summary  of  Dietary  Studies.     Quantities  and  Cost  per  Man  per  Day  (Bevier). 


Cost. 

Pro- 
tein. 

Fats. 

Car- 
bohy- 
drates. 

Fuel 

value. 

Dietary  of  a  professional  man's  family  

Cts. 

21 
13 
9 
22 
20 
16 

25 

20 

Grms. 

91 

85 
77 
147 
112 
94 

104 
103 

Grms. 

145 
104 
90 
173 
144 
121 

125 
150 

Grams. 

380 
307 
314 
683 
368 
385 

423 

402 

Cal. 

3,280 
2,575 
2,440 
5,010 
3,305 
3,085 

3,325 
3,465 

Dietary  of  a  mill  workman's  family      

Dietary  of  a  mill  workman's  family   

Dietary  of  a  boiler  tender's  family    

Average  14  dietaries  of  professional  men's  fam- 

Average  14  dietaries  of  mechanics'  families..  . 

The  following  table  is  from  the  U.  S.  Department  of  Agriculture 
Bulletin  No.  91,  and  summarizes  dietetic  studies  made  in  widely 
different  parts  of  the  United  States : 


FOODS   AND   FOOD   PREPARATIONS 


Cost,  Nutrients,  and  Fuel  Value  of  Food  per  Man  per  Day. 


Cost  of 
food. 

Pro- 
tein. 

Fats. 

Car- 
bohy- 
drates. 

Fuel 
value. 

Nutri- 
tive 
ratio. 

Teacher's   family,    Illinois: 
Food  purchased   

Cents. 
27  0 

Grams. 
124 

Grams. 
158 

Grams. 

487 

Cal. 

3975 

Food  wasted  

23 

45 

4fi 

700 

Food  eaten   

101 

113 

441 

3,275 

1-69 

Professional      men,      Connecticut, 
average  of  9  dietaries: 
Food  purchased   

25  0 

110 

136 

442 

3  530 

Food  wasted  

3 

7 

5 

100 

Food  eaten   

107 

129 

437 

3  430 

1-68 

Professional   man's   family,   Penn- 
sylvania : 
Food  purchased   

22  3 

98 

155 

396 

3  465 

Food  wasted  

7 

10 

16 

185 

Food  eaten    

91 

145 

380 

3,280 

1:78 

Teacher's  family,   Indiana: 
Food  purchased   

18  0 

111 

110 

349 

2910 

Food  wasted   

5 

8 

9 

130 

Food  eaten    

106 

102 

340 

2,780 

1-54 

Proposed   standard   for   man   with 
little  muscular  work   (Atwater) 
Mechanics'  boarding  club,  Illinois: 
Food  purchased   

23.0 

112 
128 

171 

392 

3,000 
3,720 

1  :  5.5 

Food  wasted 

11 

25 

13 

330 

Food  eaten 

117 

146 

379 

3,390 

1:61 

Mechanics'    families,    Connecticut, 
average  of  9  dietaries: 
Food  purchased   

113 

153 

420 

3,605 

Food  wasted   

7 

11 

14 

185 

Food  eaten    

106 

142 

406 

3,420 

1  •  6  9 

Mechanic's  family,  Indiana  :    ' 
Food  purchased   

26  0 

106 

157 

475 

3  840 

Food  wasted   

16 

23 

67 

555 

Food  eaten   

90 

134 

408 

3285 

1-79 

Mechanic's  family,  Tennessee: 
Food  purchased   

16  0 

119 

224 

455 

4  435 

Food  wasted   

9 

14 

43 

345 

Food  eaten    

110 

210 

412 

4  090 

1-81 

Mechanic's  family.  New  Jersey: 
Food  purchased    

28  0 

103 

144 

431 

3  530 

Food  wasted   

3 

6 

6 

95 

Food  eaten    

100 

138 

425 

3,435 

1-74 

Proposed  dietary  .standard  for  man 
with  moderate  work    (Atwater) 

125 

3,500 

1  :6.8 

A  study  by  Atwater  made  upon  the  diet  of  women  students  in 
Connecticut  showed  a  consumption  of  84  grams  protein,  128  grams 
fat,  and  264  grams  carbohydrate,  yielding  3,015  calories.  The  ac- 
cepted standard  for  woman  at  light  muscular  work  calls  for  90 
grams  of  protein  and  a  total  fuel  value  of  2,500  calories,  hence  this 
dietary  was  deficient  in  protein,  although  the  total  fuel  value  was 
considerably  above  the  standard  requirement.  This  shows  that  a 


ANIMAL  AND  VEGETABLE  FOODS  COMPARED  29 

considerable  departure  from  normal  dietetic  standards  is  not  incom- 
patible with  health. 

NUTRITION.     ANIMAL  AND  VEGETABLE  FOODS 
COMPARED 

The  study  of  nutrition  involves  the  tracing  of  the  food  products 
after  absorption  from  the  alimentary  canal,  until  their  final  excretion 
as  waste  material,  chiefly  water,  urea  and  C02. 

Animal  food  is  believed  to  make  the  blood  rich  in  fibrin  and 
corpuscles,  and  to  increase  the  mineral  salts,  especially  the  phos- 
phates ;  it  both  repairs  the  old  and  forms  new  tissue ;  it  improves  the 
condition  of  the  muscles,  which  are  made  firmer  than  they  are 
through  a  vegetable  diet,  and  favors  the  reduction  of  stored-up  or 
surplus  fat.  Under  some  conditions  it  may  produce  a  part  of  the 
body  fat,  although  most  of  it  is  derived  from  other  sources.  (See 
Obesity.)  It  also  increases  the  quantity  of  urates,  phosphates,  sul- 
phates, and  urea  normally  present  in  the  urine,  and  tends  to  make  the 
fluids  of  the  body  somewhat  more  acid  or  less  alkaline. 

Bauer  (Dietary  of  the  Sick)  says:  "The  functional  activity  and 
resisting  power  of  the  organism  seem  to  be  essentially  connected 
with  the  presence  of  an  ample  supply  of  albumin." 

Animal  food  requires  a  considerable  quantity  of  oxygen  for  its 
complete  combustion,  and  a  diet  of  this  nature  increases  the  demand 
for  oxygen.  Meat  in  general  has  a  more  stimulating  effect  upon  -the 
system  and  is  more  "strengthening"  than  vegetable  food,  and  gives 
rise  to  energy  and  activity.  A  meal  consisting  of  meat  remains  an 
hour  or  more  longer  in  the  stomach  than  a  purely  vegetable  meal. 
It  seems  to  satisfy  the  cravings  of  hunger,  bulk  for  bulk,  to  a  greater 
extent  and  for  a  longer  time  than  vegetable  food,  and  a  man  can 
live  longer  upon  exclusive  proteid  food  than  upon  exclusive  carbo- 
hydrate food.  Animal  food  occupies  less  space  in  the  stomach,  and 
is  more  portable  than  vegetable  food.  Moreover,  proteid  foods  can 
be  eaten  longer  exclusively  without  exciting  loathing,  as  a  rule,  than 
can  fats,  sugars  or  some  of  the  pure  starches.  There  is,  however,  a 
frequent,  tendency  to  eat  too  much  meat,  and  when  its  effects  are 
not  counterbalanced  by  free  outdoor  exercise,  it  produces  an  excess 
of  waste  matter  which  accumulates  and  causes  biliousness,  and  some- 
times precipitates  attacks  of  lithiasis,  gout,  etc.  A  carbohydrate  diet 
taxes  the  excretory  organs  to  a  lesser  degree  than  animal  food. 

Sir  Henry  Thompson  says :  "  It  is  a  vulgar  error  to  regard  meat 
in  any  form  as  necessary  to  life."  Nitrogenous  food  man  must 


30          FOODS  AND  FOOD  PREPARATIONS 

have,  but  it  need  not  necessarily  be  in  the  form  of  meat,  which  "  to 
many  has  become  partially  desirable  only  by  the  force  of  habit,  and 
because  their  digestive  organs  have  thus  been  trained  to  deal  with  it." 

This  is  only  partially  true,  for  the  training  has  become  so  strongly 
a  matter  of  heredity  through  many  centuries  that  those  who  possess 
it  are  certainly  in  better  health  for  a  reasonable  allowance  of  meat  in 
their  dietary,  and  many  primitive  savage  tribes  have  always  subsisted 
largely  upon  meat.  Errors  in  diet  are  far  more  common  on  the  side 
of  excessive  meat  eating  than  the  eating  of  too  much  vegetable  food, 
especially  among  civilized  communities.  In  the  temperate  zones  an 
increase  in  prosperity,  together  with  the  improvements  made  in  the 
methods  of  preparing  and  preserving  meat  as  well  as  those  in  breed- 
ing cattle  for  market  purposes,  tend  to  increase  the  habit  of  meat 
eating.  The  common  estimate,  in  which  meat  should  occupy  one- 
sixth  and  vegetable  food  five-sixths  of  a  mixed  diet,  is  overstepped 
by  many  persons  with  whom  the  proportion  may  be  three  or  four  to 
six.  An  average  of  eighty-seven  practical  dietary  studies  made  by 
the  U.  S.  Department  of  Agriculture  showed 'that  the  food  consumed 
was  45  per  cent  of  animal  and  55  per  cent  of  vegetable  origin. 

The  proper  association  of  different  foods  always  keeps  healthy  men 
in  better  condition  than  too  long  continuance  of  any  selected  diet  sys- 
tem. 

Meats  which  are  deficient  in  fat  are  usually  eaten  with  added  fat. 
Thus  bacon  is  eaten  with  veal,  liver,  and  chicken,  and  most  fish  are 
cooked  with  butter  or  oil.  Similarly,  butter,  eggs,  or  cream  are 
mixed  with  amylaceous  foods,  such  as  rice,  sago,  potatoes,  etc.,  which 
are  lacking  in  fat,  and  cheese  containing  fat  is  added  to  macaroni. 
Bacon  is  added  to  beans,  and  pork  to  greens. 

"  Whenever  one  kind  of  food  is  wanting  in  any  particular  con- 
stituent, we  invariably  associate  it  with  another  that  contains  an 
excess  of  it"  (Letheby). 

If  a  laboring  man  is  allowed  an  ordinary  meat  ration  he  requires 
in  addition,  to  obtain  his  requisite  carbon,  of  fat  346  grams,  or 
of  starch  596  grams  (Voit).  But  he  would  soon  tire  of  such  a 
quantity  of  either  of  these  two  food  classes  alone,  and  he  does  better 
to  eat  some  of  each.  As  pointed  out  by  Voit  more  than  forty  years 
ago,  the  available  vegetable  nutrients  are  so  enclosed  in  cellulose  or 
woody  fiber  as  to  render  their  absorption  difficult.  Vegetable  food 
eaten  in  excess  is  liable  to  induce  intestinal  fermentation,  which  ex- 
cites peristalsis,  and  as  the  intestine  of  man  is  much  shorter  than 
that  of  herbivores,  this  class  of  food  does  not  have  time  for  complete 
absorption,  when  consumed  in  too  large  amount. 


ANIMAL  AND  VEGETABLE   FOODS  COMPARED  31 

The  carnivorous  animal  fed  upon  lean  meat  alone  requires  a  daily 
supply  equal  to  one-twentieth  of  his  body  weight,  but  if  a  little  fat 
be  added  he  needs  much  less. 

Animal  food  is  often  said  to  be  more  stimulating  to  the  passions 
than  vegetable  food,  and  in  general  the  character  of  carnivorous  ani- 
mals is  more  savage  than  that  of  herbivorous,  although  the  angered 
bull  is  as  fierce  as  any  carnivore.  It  is  doubtful,  however,  whether 
this  is  attributable  so  much  to  their  different  diet  as  to  many  other 
conditions  which  have  contributed  through  the  survival  of  the  fittest 
to  their  differentiation.  Carnivorous  animals  are  obliged  to  work 
and  fight  for  their  food;  they  obtain  it  at  uncertain  and  infrequent 
intervals,  often  when  made  ravenous  by  long  periods  of  fasting. 
Herbivorous  animals,  on  the  contrary,  always  have  their  food  at  hand, 
obtainable  with  little  labor  other  than  that  of  eating.  The  Polynesian 
warrior  is  more  ferocious  at  times  on  a  diet  of  plantains  than  the 
Eskimo,  who  eats  nothing  but  fish,  meat,  and  fats. 

A  man  cannot  perform  more  actual  muscular  labor  upon  an  ex- 
clusive diet  of  animal  food  than  of  starchy  food.  He  requires  abun- 
dant animal  food  to  replace  the  general  wear  and  tear  of  muscular 
tissue,  but  the  energy  for  muscular  contraction  is  not  derived  so  much 
from  proteid  food,  as  from  carbohydrates,  the  former  being  used 
merely  to  keep  the  muscles  in  a  state  of  healthful  equilibrium. 
He  who  is  physically  feeble  and  who  lacks  muscular  power  cannot 
restore  that  power  by  an  exclusive  proteid  diet.  A  man  fed  upon 
proteid  diet  without  vegetable  food  may  not  work  as  well  in  daily 
labor  as  when  given  a  fair  proportion  of  the  latter ;  but,  on  the  other 
hand,  he  is  better  fitted  for  sudden  arduous  exertion  than  are  exclusive 
vegetable  feeders. 

A  mixed  diet  is  therefore  the  only  rational  one  for  civilized  man, 
and  it  is  useless  to  reason  otherwise  from  analogy  with  the  lower  ani- 
mals, or  from  certain  savage  tribes  whose  peculiar  development  ex- 
empts them  from  general  rules.  The  ox  is  strong  and  performs  daily 
labor  upon  a  grass  diet,  but  he  extracts  a  large  proportion  of  nitrogen 
from  such  food  which  man's  feebler  digestive  organs  do  not  enable 
him  to  do.  The  proportion  of  protein  to  carbohydrate  is  1  to  4.7  in 
such  food.  The  horse  is  fed  upon  oats  when  it  is  desired  to  increase 
his  spirit  and  activity,  and  he  derives  more  nitrogen  from  them  than 
does  man  from  his  oatmeal.  The  lion  derives  great  strength  from 
purely  nitrogenous  food,  but  when  trained  he  is  wholly  unfit  for 
the  continuous  exertion  that  herbivores  can  endure. 

The  northern  Eskimo,  who  has  absolutely  no  starchy  or  saccha- 
rine food,  eats  fat  with  his  protein  diet,  and  is  therefore  enabled  to 


FOODS  AND  FOOD  PREPARATIONS 

acquire  energy  to  resist  extreme  cold  and  to  take  very  long  and 
fatiguing  sledge  journeys;  yet  he  is  no  stronger,  nor  as  strong,  as 
the  Central  African  negro,  who  lives  upon  a  diet  of  manioc  and  plan- 
tains, without  meat. 

"  Some  food  rich  in  protein  will  be  found  in  the  daily  diet  of  all 
peoples.  The  Mongol  eats  with  his  rice,  which  is  largely  starch, 
small  quantities  of  fish,  fish  eggs,  and  goose  livers,  but  for  his  supply 
of  protein  material  he  relies  on  his  different  preparations  of  bean 
cheese  and  on  soja  sauce  made  from-  the  soy  bean.  The  Mexican, 
whose  supply  of  meat  is  scanty  and  of  a  poor  quality,  uses  the  native 
bean  or  frijole  at  almost  every  meal,  made  into  a  stew  with  vegetables 
and  perhaps  shreds  of  sun-dried  beef,  well  spiced  with  the  chili  or 
red  pepper"  (Mary  Hinman  Abel). 

Man  is  an  animal  of  extraordinary  adaptability  to  his  environment., 
and  one  should  be  guarded  in  making  dogmatic  statements  in  regard 
to  his  diet,  and  such  observations  as  the  above  should  be  taken  as  ap- 
plying only  generally,  for  it  seems  possible  for  either  class  of  foods  to 
supplement  to  some  extent  the  functions  of  the  other.  This  fact  is 
illustrated  in  disease  as  well  as  in  health.  For  example,  in  the  earlier 
stages  of  diabetes  glucose  is  formed  from  farinaceous  and  saccharine 
food  almost  exclusively,  but  in  the  advanced  stages,  when  these  sub- 
stances are  withheld,  it  undoubtedly  may  be  derived  from  proteid 
material. 

It  is  a  popular  belief  that  meat  requires  more  effort  for  digestion 
than  starchy  food,  but  in  health  this  is  probably  not  true,  provided 
both  varieties  of  food  are  taken  in  correct  proportion,  for  it  certainly 
would  be  a  strain  upon  the  digestive  system  to  be  obliged  to  derive 
all  the  carbon  needed  from  an  exclusive  meat  diet,  just  as  it  over- 
taxes the  alimentary  canal  to  obtain  sufficient  nitrogenous  material 
from  an  exclusive  vegetable  diet.  It  cannot  be  said  didactically  that 
a  piece  of  beef  is  more  or  less  digestible  than  a  potato,  and  that  it 
taxes  the  energies  of  the  digestive  organs  to  a  greater  extent,  al- 
though it  is  more  completely  assimilated  and  leaves  less  waste  in 
the  intestine.  The  whole  question  devolves  upon  a  true  balance  of 
the  ingredients  of  a  mixed  diet.  As  regards  the  actual  complexity 
of  the  digestive  processes  of  the  several  classes  of  food,  there  is  but 
little  difference,  for  both  starches  and  proteids  pass  through  interme- 
diate stages  on  the  way  to  the  formation  of  their  completed  products. 
In  man,  certainly.  Xature  never  intended  that  all  the  nutrition  of 
the  body  should  he  derived  from  any  one  class  of  food  stuff  which 
would  require  the  use  of  certain  digestive  juices,  and  imply  the  disuse 
of  other?  which  arc  normally  present. 


VEGETARIANISM  33 

A  diet  of  animal  food  is  much  less  fattening  than  a  vegetable 
regimen  or  than  carbohydrates  with  a  fair  proportion  of  fats,  but  a 
stout  man  does  not  endure  fatigue,  or  even  starvation,  better  than 
a  lean  man.  On  the  other  hand,  to  increase  the  proteid  substances 
of  the  body  an  albuminous  diet  with  little  carbohydrate  is  neces- 
sary. Men,  unless  greatly  emaciated,  have  a  reserve  store  of  energy 
in  their  bodies  sufficient  to  maintain  their  animal  heat  and  keep  them 
alive  for  from  seven  to  nine  days,  and  this  is  true  whether  they  have 
been  meat  eaters  or  vegetarians.  Storage  of  fat  will  help  them  out  in 
emergencies,  but  if  it  has  been  overdone  —  i.  e.,  if  there  is  too  much 
fat  in  the  tissues  —  they  may  be  weakened  by  it  and,  although  they 
have  the  material  for  force  production  on  hand,  they  are  unable  to 
utilize  it,  and  are  worse  off  than  if  they  were  spare.  (See  Obesity 
and  Leanness.) 

Bauer  wrote :  "  The  material  effects  of  albumin  and  of  fat  in  the 
system  are  in  a  certain  sense  opposed,  for  the  former  increases  the 
tissue  waste  and  secondarily  the  oxidation,  while  fat  induces  the  op- 
posite effects."  When  the  organism  is  in  health  albumin  constitutes 
upon  the  average  about  10  per  cent  of  the  body  weight  and  fat  about 
16  per  cent,  but  these  proportions  may  vary  within  wide  limits. 

Animal  food  is  easily  cooked,  requiring  less  fuel  than  vegetable  food, 
and  in  the  process  develops  more  flavor  than  has  vegetable  food. 

VEGETARIANISM 

In  regard  to  an  exclusive  or  almost  exclusive  vegetable  diet  for  civ- 
ilized man,  the  universal  experience  has  been  that  while  it  may  keep 
him  in  apparent  health  for  some  time,  it  eventually  results  in  a  loss  of 
strength  and  general  resisting  power  against  disease,  which  becomes 
evident  after  some  months,  if  not  before. 

Of  vegetarianism  Bauer  wrote :  "  The  beneficial  effects  of  vege- 
tarianism certainly  do  not  depend  on  the  fact  that  its  followers  take 
no  meat,  and  still  more  no  animal  food,  but  on  their  giving  up  their 
former  bad  habits." 

No  doubt  much  of  the  alleged  benefit  of  vegetarianism  is  due  to 
the  greater  freedom  of  action  of  the  bowels,  induced  by  the  use  of 
bran  bread  and  other  coarse  articles  of  food. 

Those  who  style  themselves  "vegetarians"  are  of  several  classes: 
(1)  Those  who  eat  no  meat,  but  eat  other  forms  of  proteid  food, 
often  in  the  form  of  puddings,  pastry,  etc.,  containing  much  milk 
and  eggs.  (2)  Strict  vegetarians,  eating  only  vegetables  and  cereals 
(3)  Fruitarians,  who  subsist  upon  fruits  and  nuts  and  sometimes 


34 


FOODS  AND  FOOD  PREPARATIONS 


cereals.     A  sample  diet  of  the  latter,  for  a  woman  30  years  old, 
weighing  104  Ibs.,  is  given  as  follows  by  M.  E.  Jaffa : 

Weights  of  Food  and  Nutrients  Consumed. 


Kinds  and  amounts  of  different  food 
materials. 

Composition  of  food  per  person  perday. 

Pro- 
tein. 

Fat. 

Sugar, 
starch, 
etc. 

Crude 
fiber. 

Fuel 

value. 

VEGETABLE   FOOD. 

Vegetables:    Celery,    113    grams;    tomatoes, 
3  624   grams    

Grams. 

2 

5 

Grams. 
I 

1 

Grams. 
5 

45 
3 

Grams. 
1 

24 

1 

Cal. 
40 

370 

15 
95 
45 

475 

Fresh     fruits:     Apples,     Astrachan,     9,130 
grams;    apricots,   3,360   grams;    figs,   408 
grams;   olives,   630   grams;    oranges,   822 
grams;     peaches,     4,711     grams;     pears, 
1,755      grams;      plums,      Japanese,      900 
grams-  plums,  red,  1,080  grams  

Dried  fruits:   Dates,  93  grams;   raisins,  60 
grams    

Vegetable  oils:  Olive  oil,  255  grams   

10 

Honey,  337  grams    

11 

8 

Nuts;   Almonds,   1,067  grams;   Brazil  nuts, 
146    grams;    pignolias,    765    grams,    pine 
nuts,  142  grams  ;  walnuts,  672  grams  .  .  . 

Total  vegetable  food   

18 

39 

1 

25 

57 

72 

27 

1,040 

As  the  normal  standard  diet  for  a  woman  at  light  work  should 
comprise  2,500  calories,  it  is  seen  that  the  above  diet,  although  per- 
sisted in  for  twenty-five  days,  fell  much  below  half  the  standard 
required  for  continued  maintenance  of  health  and  strength. 

It  is  impossible  to  subsist  for  any  length  of  time  on  a  diet  which 
does  not  contain  a  considerable  quantity  of  nitrogen,  which  con- 
stitutes so  important  an  element  in  the  composition  of  the  great 
majority  of  structures  of  the  body,  in  fact,  of  protoplasm  itself. 

Attempts  have  been  made  from  time  to  time,  for  economic  rea- 
sons, to  furnish  large  bodies  of  laboring  men,  employed  by  con- 
tract or  otherwise,  with  a  purely  vegetable  diet;  but  this  diet  is 
found  to  defeat  its  own  ends,  in  that  the  maximum  of  labor  can- 
not be  maintained  by  men  who  are  fed  exclusively  on  vegetable 
food,  although  some  carbohydrates  are  essential.  It  gradually  in- 
duces a  condition  of  muscular  weakness  and  languor  with  disincli- 
nation for  either  physical  or  mental  work.  In  support  of  this  state- 
ment Yigsford  relates  that  for  the  construction  of  a  railway  from 
Paris  to  Itouen,  English  and  French  workmen  were  employed. 
The  former  did  one-third  more  work  than  the  French,  until  in  the 
French  diet  roast  beef,  as  in  the  diet  of  the  English,  was  substituted 


VEGETARIANISM  35 

for  bouille  and  soup,  after  which  the  work  done  by  the  two  gangs  of 
men  was  equalized. 

In  referring  to  graminivorous  people,  like  the  Bengalese,  Cham- 
bers wrote :  "  If  required  to  exert  themselves  in  any  unusual  way 
when  food  is  deficient,  they  simply  die.  The  reason  is  evident  — 
they  have  been  living  on  their  own  tissues,  and  the  small  quantity 
of  albuminous  matter  in  grain  is  a  long  time  in  building  them  up 
again,  so  that  for  weeks,  or  even  months,  their  muscles  are  in  a  state 
of  atrophy ." 

Animal  food  in  some  form  must  be  regarded  as  absolutely  essen- 
tial for  all  vigorous  races.  When  the  diet  of  enthusiastic  "vege- 
tarians "  is  carefully  investigated  it  is  found  that  the  strictly  carbohy- 
drate food  is  supplemented  by  such  articles  as  milk,  eggs,  etc.,  which 
are  used  in  cooking  or  in  other  ways,  although  the  consumption  of  ni- 
trogenous food  may  appear  very  much  restricted. 

It  is  believed  by  Giibler  and  others  that  an  exclusive  vegetable 
diet  eventually  develops  an  atheromatous  condition  of  the  arteries, 
on  account  of  the  large  proportion  of  mineral  salts  which  thus  enter 
the  blood,  but  the  evidence  of  this  is  not  convincing.  It  is  also 
claimed  that  a  vegetable  diet  favors  the  deposition  of  mineral  salts 
in  different  parts  of  the  body,  as  phosphatic  stone,  gravel,  and  the 
tartar  on  the  teeth,  and  that  living  upon  coarse  cereals  alone  makes 
the  skin  rough,  and  the  individual  dull,  heavy,  and  ill-tempered. 

While  it  is  quite  true  that  some  kinds  of  vegetables  contain  a  large 
proportion  of  nitrogenous  substance,  it  exists  in  a  form  in  which  it 
is  less  easily  assimilated  than  animal  proteid.  In  vegetable  foods 
nitrogenous  materials  are  more  or  less  closely  mingled  with  starch. 
Cellulose  itself  is  often  very  tough  and  insoluble  in  the  digestive 
fluids,  so  that  as  large  a  proportion  of  protein  as  17  per  cent  may  be 
wasted,  while  not  over  3  per  cent  of  the  protein  of  animal  food  re- 
mains undigested.  This  is  an  important  illustration  of  the  fact  that 
one  must  not  be  guided  by  chemical  composition  alone  in  selecting 
the  proper  dietary  for  man,  but  the  question  should  rather  depend 
upon  the  actual  nutrient  value  of  the  food  when  absorbed. 

There  are  many  facts  in  Nature  in  addition  to  those  already 
discussed  which  indicate  without  doubt  that  man  from  his  earliest 
prehistoric  days  has  been  omnivorous,  adapting  himself  to  his  sur- 
roundings and  eating,  in  his  primitive  condition,  whatever  his  envi- 
ronment afforded,  with  least  expenditure  of  labor  to  obtain  it,  now 
vegetable,  now  animal  food.  This  is  shown  in  the  structure  of  the 
teeth  in  prehistoric  skulls,  and  in  the  length  of  the  alimentary  canal 
and  character  of  the  digestive  organs  and  secretions  as  at  present 


36  FOODS  AND  FOOD  PREPARATIONS 

existing.  There  would  be  little  use  in  providing  man  with  pepsin 
and  a  strongly  acid  gastric  juice,  were  it  not  intended  by  Nature 
for  the  digestion  of  meats. 

A  brief  glance  at  the  dietetic  habits  of  the  primitive  tribes  of 
mankind  at  present  living  shows  that  no  arguments  may  be  drawn 
from  them  as  to  the  advantages  of  any  particular  class  of  foods. 

The  ancient  Britons  are  known  to  have  subsisted  largely  upon 
acorns,  berries,  roots,  leaves,  etc.,  but  other  primitive  tribes  ate  fish, 
shellfish,  and,  when  they  could  kill  it,  game. 

Many  savage  tribes  to-day  live  very  largely  upon  vegetable  food, 
although  an  exclusive  vegetable  diet  is  almost  unknown  among 
them,  and  most  of  them  eat  meat  whenever  they  can  obtain  it,  or 
they  supplement  their  food  by  nitrogenous  articles,  such  as  milk, 
eggs,  fish,  and  insects  of  various  kinds.  The  Chinese  and  Japanese 
coolies,  who  subsist  principally  upon  simple  farinaceous  food,  such 
as  rice,  eat  also  eggs,  fish,  pork,  and  chicken.  On  the  other  hand, 
there  are  tribes  of  men  inhabiting  very  hot  countries  who  eat  con- 
siderable quantities  of  meat,  as,  for  example,  the  Nubian  Arabs  and 
Abyssinians,  and  some  Mongolians  live  by  their  herds  —  upon  milk 
products  and  meat  —  bread  being  scarcely  known  to  them.  The 
Australian  savage  is  omnivorous,  and,  having  no  cereals,  he  subsists 
upon  berries,  beans,  pith,  nuts,  honey,  larvae,  ants,  etc.  The  Papuan 
Islanders  live  chiefly  upon  sago,  fish,  and  fruits.  The  New  Cale- 
donians were  formerly  cannibals,  but  are  now  vegetarians  by  prefer- 
ence, and  prefer  to  trade  their  pigs  and  goats  with  passing  ships 
rather  than  to  eat  them. 

Vegetarianism  in  former  times  has  had  many  famous  advocates. 
Shelley  was  a  vegetarian,  so  was  Jean  Jacques  Rousseau,  and  Gold- 
smith also  at  one  time.  There  is  a  Vegetarian  Society  in  England 
which  has  established  restaurants  in  London,  Manchester,  and  sev- 
eral other  localities.  In  London  there  are  upward  of  4,000  mem- 
bers of  this  Society.  There  is  a  similar  organization  in  this  country. 
The  creed  of  esoteric  Buddhism  has  induced  some  persons  in  this 
country  to  adopt  vegetarian  habits,  but  few  of  them  adhere  to  them 
strictly  or  for  long-. 

THE  CLASSES  OF  FOODS  — I.  WATER 

Tt  is  estimated  that  water  composes  about  70  per  cent  of  the 
entire  body  weight,  and  it  is  an  almost  universal  solvent.  Its  im- 
portanco  to  the  system,  therefore,  cannot  be  overrated.  The  elastic- 
ity or  pliability  of  muscles,  cartilages,  and  tendons,  and  even  of 


WATER  37 

bones,  is  in  great  part  due  to  the  water  which  these  tissues  contain. 
As  Solis-Cohen  says,  "  the  cells  of  the  body  are  aquatic  in  their 
habits."  The  amount  of  water  required  by  a  healthy  man  in  twenty- 
four  hours  is,  on  the  average,  between  60  and  70  ounces,  besides 
about  20  ounces  taken  in  as  an  ingredient  of  solid  food,  thus  making 
a  total  of  80  to  90  ounces.  The  elimination  of  this  water  is  divided 
as  follows:  28  per  cent  through  the  skin,  20  per  cent  through  the 
lungs,  50  per  cent  through  the  urine,  2  per  cent  through  other  secre- 
tions and  the  feces.  This  is,  of  course,  a  very  general  computation, 
for  there  is  constant  variation  in  the  activity  of  different  organs. 

A  large  proportion  of  the  water  is  taken  in  the  form  of  beverages 
composed  chiefly  of  it,  and  by  many  persons  they  are  substituted  for 
plain  water  altogether.  In  some  countries  light  wines,  beer,  and 
other  fermented  drinks  wholly  replace  drinking  water.  This  may  be 
due  to  habit  and  custom,  or  to  necessity  from  lack  of  pure  natural 
water,  but  in  all  cases  the  quantity  of  water  required  to  maintain  the 
functions  of  the  body  in  healthful  activity  remains  the  same,  whether 
it  be  drunk  pure  or  in  beverages,  or  taken  with  succulent  fruits  and 
vegetables,  or  in  milk,  koumiss,  etc. 

One  of  the  most  universal  dietetic  faults  is  neglect  to  take  enough 
water  into  the  system. 

Uses  of  Water  in  the  Body. —  The  uses  of  water  in  the  body  may 
be  summarized  as  follows: 

1.  It  enters  into  the  chemical  composition  of  the  tissues. 

2.  It  forms  the  chief  ingredient  of  all  the  fluids  of  the  body  and 
maintains  their  proper  degree  of  dilution. 

3.  By  moistening  various  surfaces  of  the  body,  such  as  the  mucous 
and  serous  membranes,  it  prevents  friction. 

4.  It  furnishes  in  the  blood  and  lymph  a  fluid  medium  by  which 
food  may  be  taken  to  remote  parts  of  the  body  and  the  waste  mat- 
ter removed,  thus  promoting  rapid  tissue  changes. 

5.  It  serves  as  a  distributor  of  body  heat. 

6.  It  regulates  the  body  temperature  by  the  physical  processes  of 
absorption  and  evaporation. 

The  taking  of  much  water  into  the  stomach  by  its  mechanical 
pressure  excites  peristalsis.  One  or  two  tumblerfuls  of  cold  water 
taken  into  an  empty  stomach  in  the  morning  on  rising  favor  evacua- 
tion of  the  bowels  in  this  way.  The  water,  moreover,  is  quickly  ab- 
sorbed and  temporarily  increases  the  fullness  of  the  blood  vessels. 
This  promotes  intestinal  secretion  and  peristalsis.  The  increased 
activity  of  the  lower  bowel  is  thus  explained  rather  than  by  the  idea 
that  the  water  itself  reaches  the  colon  and  washes  out  its  contents, 


FOODS   AND   FOOD   PREPARATIONS 

Lukewarm  water  acts  as  a  mild  emetic  if  drunk  in  large  quantity. 
This  action  fails  above  95°  F.  and  below  60°  F.,  and  is  most  efficient 
at  about  90°  F. 

Purity  of  Water. —  Of  recent  years  the  importance  of  insuring 
the  purity  of  drinking  water  has  become  more  and  more  appreciated, 
and  an  intelligent  public  is  now  aroused  to  the  absolute  necessity  of 
protecting  their  supplies  of  drinking  water  from  contamination  with 
sewage,  decomposing  animal  matter,  etc.  So  general  has  the  interest 
in  this  subject  become  in  this  country  that  new  laws  are  being  passed 
constantly  to  protect  the  water  supply  of  large  cities  and  towns.  The 
subject  is  not  confined  to  water  alone,  but  includes  ice  as  well,  for 
many  of  the  germs  and  organic  impurities  of  water  are  not  destroyed 
by  freezing,  and  impure  ice  added  to  pure  water  contaminates  it.  It 
has  been  proved  very  clearly  that  certain  infections  may  be  conveyed 
through  the  agency  of  water;  such  are  the  germs  of  typhoid  fever, 
dysentery,  and  cholera.  An  excess  of  decayed  vegetation  in  water 
may  render  it  aesthetically  unpleasant,  but  not  necessarily  unwhole- 
some, provided  no  specific  germs  are  present. 

Varieties  of  Drinking  Water. —  Water  containing  a  moderate 
quantity  of  mineral  salts,  4  or  5  grains  to  the  gallon,  is  not  to  be 
regarded  as  impure,  but  the  composition  as  well  as  the  quantity  of 
these  salts  affect  its  power  as  a  solvent  in  the  tissues,  and  may  exert 
a  very  decided  influence  upon  the  digestive  system  when  present  in 
the  proportion  of  60  or  70  grains  to  the  gallon.  The  mineral  waters 
may  contain  much  more. 

Hard  and  Soft  Water. — An  excess  of  lime  salts  and  of  other  min- 
eral matters  in  water  produces  constipation,  flatulence,  indigestion, 
and  favors  the  formation  of  calcareous  deposits  in  various  parts  of 
the  body.  By  boiling,  the  "  hardness  "  of  water,  which  is  due  to  the 
presence  of  earthy  carbonates,  is  diminished,  for  the  carbonic-acid, 
which  aids  in  holding  them  in  suspension,  is  driven  off.  Water  is  also 
improved  for  drinking  by  filtering  through  a  filter  paper,  or  clean 
absorbent  cotton  on  a  funnel.  Boiling  the  water  does  not  precipitate 
neutral  and  alkaline  salts,  and  a  purgative  action  may  still  remain 
if  they  are  present.  "  Hard  "  water  is  made  more  assimilable  by  con- 
verting it  into  barley  or  oatmeal  water.  Water  which  contains  sul- 
phate of  lime  causes  gastric  distress  and  dyspepsia,  and  it  may  form 
calculi.  "  Soft  water "  is  water  which  is  free  from  objection- 
able salts.  It  is  more  wholesome  than  hard  water.  Hard  and  soft 
water  have  well-known  characteristics  in  regard  to  their  effect  upon 
the  cooking  of  food.  Calcareous  drinking  waters,  and  especially  wa- 
ters derived  from  melting  snow  or  glaciers,  have  been  believed  to 


WATER  39 

be  factors  in  the  development  of  goiter  and  cretinism,  notably  in 
Switzerland  and  the  Austrian  Tyrol,  but  many  cases  occur  in  which 
such  theory  is  untenable. 

Rain  Water. —  Next  to  clear  mountain-spring  water  which  has  run 
through  gravel  and  been  well  aerated,  rain  water  at  the  close  of  a 
shower  and  fresh  snow  water  are  the  purest  forms  of  natural  waters 
excepting  where  the  rain  water  has  fallen  through  a  very  dusty  or 
smoky  atmosphere  or  run  over  a  dirty  roof.  The  first  drops  of  a 
shower  carry  down  with  them  the  impurities  of  the  air,  including 
traces  of  ammonia  and  nitric  acid.  No  natural  water  possesses  abso- 
lute chemical  purity,  but  water  collected  at  the  end  of  a  hard  or  long 
shower  is  very  pure,  having  been  distilled  by  previous  evaporation. 

River  water  which  has  run  over  a  rocky  or  gravel  bed,  and  has 
been  well  aerated,  is  quite  pure  if  properly  protected  from  sources  of 
pollution.  Free  oxidation  makes  much  organic  matter  harmless. 
Flowing  water,  by  oxidation  and  dilution,  becomes  purified  to  a  great 
extent  of  injurious  organic  matter,  but  is  not  necessarily  deprived  of 
living  germs  of  contagion,  such  as  those  of  typhoid  fever  or  cholera. 

It  is  now  so  well  recognized  that  the  impurities  of  water  which 
are  chiefly  dangerous  to  man  are  of  organic  germ  origin  that  in 
examining  water  which  is  suspected  of  being  the  cause  of  a  typhoid- 
fever  epidemic  a  chemical  analysis  of  the  nitrates  present,  unaccom- 
panied by  a  proper  bacteriological  examination,  is  entirely  useless. 

Distilled  Water. — Distilled  water  is  absolutely  pure,  but  it  has  a 
flat  or  metallic  taste  from  absence  of  air  and  salts.  The  flat  taste 
may  to  some  extent  be  improved  by  agitating  the  water  with  air  in  a 
carafe.  It  is  now  extensively  furnished  for  drinking,  and  is  largely 
in  use  on  vessels  at  sea.  Distilled  water  has  been  recommended  as  a 
solvent  for  renal  and  vesical  calculi,  but  it  is  of  doubtful  efficacy. 

Filtered  Water. —  Filtration  as  employed  to  render  drinking  water 
more  pure  is  a  very  delusive  process,  unless  great  care  be  taken  as 
to  the  construction  of  the  filter  and  the  rate  of  filtration.  Extensive 
experiments  made  at  Providence,  E.  I.,  and  Lawrence,  Mass.,  have 
proved  that  the  benefit  of  sand  filtration  of  city  water  results  only 
when  the  filters  are  frequently  cleaned.  The  sand  layer  should  not 
be  less  than  30  centimetres  thick,  nor  the  rate  of  water  flow  fall 
below  100  millimetres  per  second.  Frequent  bacteriological  ex- 
amination of  the  water  should  be  made.  Koch  has  shown  that  it 
is  not  the  sand  which  "  filters,"  but  the  layer  of  mud  or  slime  which 
is  deposited  upon  it  and  which  retains  bacteria.  In  Albany,  New 
York,  the  reduction  in  number  of  typhoid  cases  after  the  adoption  of 
filtration  was  73  per  cent;  in  Binghamton,  72  per  cent,  and  in  Ithaca, 


40          FOODS  AND  FOOD  PREPARATIONS 

78.3  per  cent.  A  great  variety  of  patent  filters  have  been  devised,  and 
they  have  the  power  of  making  water  appear  pure  by  decolorizing  it 
and  removing  visible  organic  particles  and  grosser  impurities  which  it 
may  contain,  but  it  has  been  shown  conclusively  that  the  bed  of  a  filter 
which  has  been  in  use  for  some  time  furnishes  a  favorable  soil  or 
culture  medium  for  the  development  of  germs,  which  increase  very 
rapidly  until  they  reach  such  numbers  that  they  are  washed  out  with 
the  filtered  water,  rendering  it  much  more  injurious,  in  some  in- 
stances, than  it  was  before. 

Boiled  Water. —  Boiled  water  is  antifermentative  and  aseptic, 
i.  e.,  it  is  sterilized. 

The  object  of  boiling  the  water  which  is  to  be  used  for  drinking 
purposes,  or  in  the  preparation  of  food,  is  to  free  it  from  organic 
impurities,  and  in  some  cases  to  precipitate  salts  of  lime.  There  are 
no  species  of  germs,  and  there  are  no  ferments  which  are  not  killed 
by  a  longer  or  shorter  exposure  to  the  temperature  of  boiling  water, 
i.  e.,  212°  F.  The  process  consists  in  the  application  of  heat  to  water 
in  sufficient  degree  to  expand  the  air  which  it  naturally  absorbs  and 
which  rises  to  the  surface  in  bubbles  of  various  sizes.  If  the  water 
contains  gases  of  decomposition  they  are  expelled,  and  the  odor  is  most 
foul  just  before  the  boiling  point  is  reached ;  later  it  passes  off,  show- 
ing when  the  water  is  fit  to  drink.  When  boiled  water,  cooled,  is 
drunk  it  tastes  "  flat  "  or  insipid,  but  it  may  be  freshened  like  distilled 
water  by  pouring  it  through  the  air  from  one  vessel  to  another  or  by 
shaking  it  with  air  in  a  carafe.  Water  should  always  be  boiled  before 
being  drunk  if  there  is  the  slightest  suspicion  as  to  its  purity.  The 
population  of  the  larger  Chinese  cities  is  exceedingly  dense,  and  the 
water  used  by  the  inhabitants  is  impregnated  with  all  manner  of  filth, 
but  the  custom  of  the  natives  of  drinking  tea  infused  with  boiling 
water,  protects  them  to  a  great  extent  from  the  ravages  of  certain 
microbic  diseases. 

The  special  dietetic  uses  of  water  will  receive  attention  under  the 
appropriate  headings  of  different  diseases. 

Water  may  be  of  service  to  eliminate  waste  in  various  renal  dis- 
eases, gout,  lithiasis,  oxaluria,  renal  inadequacy,  fevers,  and  infectious 
diseases.  If  imbibed  too  freely  with  meals  it  lessens  by  dilution  the 
activity  of  the  saliva  and  gastric  juice.  Water  taken  near  the  end  of 
the  gastric  digestion  of  a  meal  (i.  e.,  two  or  three  hours  after  taking 
food)  serves  to  dilute  the  contents  of  the  stomach  and  wash  it  more 
promptly  into  the  intestine.  If  stomach  digestion  has  been  slow  and 
feeble,  so  that  the  whole  process  has  been  greatly  prolonged,  the  drink- 
ing of  six  or  eight  ounces  of  water,  either  hot  or  cold,  two  hours  or 


WATER  41 

more  after  taking  food  will  facilitate  its  digestion.  Water  is  highly 
useful  in  constipation.  It  is  more  quickly  absorbed  from  the  stomach 
or  intestine  when  the  tension  in  the  blood  vessels  is  low. 

It  is  imperatively  needed  after  severe  hemorrhage,  or  after  the 
sudden  loss  of  it  from  the  system  from  any  cause,  such  as  the  evacu- 
ations of  cholera  morbus,  Asiatic  cholera,  etc.,  in  which  conditions  it 
may  be  injected  in  the  rectum,  subcutaneously  or  intravenously  as 
"normal  salt  solution,"  i.  e.,  a  0.7  per  cent  solution  of  common  salt. 

The  use  of  water  is  to  be  restricted  in  dilatation  of  the  stomach,  the 
secretion  of  weak  gastric  juice,  and  sometimes,  but  not  always,  in 
diabetes  insipidus,  diabetes  mellitus,  ascites  and  other  dropsies,  ana- 
sarca,  and  in  some  forms  of  heart  disease  and  obesity. 

The  daily  quantity  of  water  ordinarily  drunk  varies  between  two 
and  a  half  and  four  pints.  About  one  and  a  half  pint  more  is  taken 
in  the  food,  and  four  and  a  half  or  five  pints  are  therefore  lost  through 
the  emunctories. 

Natural  foods  which  contain  most  water  are  milk  and  succulent 
fruits,  such  as  grapes,  oranges,  grape  fruit,  lemons,  melons,  plums, 
peaches,  etc.,  and  vegetables  like  the  tomato,  squash,  and  many  others 
of  tropical  origin.  All  vegetables  contain  more  water  than  meats,  and 
many,  but  not  all,  ripe  fruits  contain  more  than  vegetables. 

Excess  of  Water. —  There  is  a  remarkable  tendency  on  the  part 
of  the  blood  to  maintain  equilibrium  as  regards  its  own  composi- 
tion, volume,  and  density.  When  a  large  supply  of  water  is  re- 
ceived in  the  alimentary  canal  and  absorbed  by  the  blood  vessels, 
the  blood  is  momentarily  diluted  and  the  blood  pressure  slightly 
raised,  although  the  latter  effect  will  depend  upon  the  facility  with 
which  the  blood  vessels  are  dilated.  The  blood  immediately  dis- 
tributes the  water  thus  absorbed,  and  the  slightly  increased  pressure, 
as  well  as  the  diluted  character  of  the  blood,  hastens  the  elimination 
of  water  from  the  various  gland  surfaces.  The  kidneys  are  particu- 
larly sensitive  in  this  respect,  and  when  in  normal  condition  are  the 
great  regulators  of  the  composition  of  the  blood  and,  indirectly,  of 
blood  pressure  by  means  of  the  elimination  of  water.  Perspiration 
is  increased.  There  is  a  tendency  also  for  all  the  tissues  to  keep 
abundantly  supplied  with  water;  a  large  amount  of  aqueous  vapor 
is  exhaled  from  the  surface  of  the  lungs,  and  the  digestive  secretions 
are  increased  in  volume.  The  blood  subsequently  may  become 
more  dense  than  before,  owing  to  the  increased  functional  activity 
of  different  organs.  More  nutriment  is  absorbed  and  more  carbonic- 
acid  is  exhaled,  and  urea  and  uric-acid  elimination  may  be  slightly 

increased. 
6 


42          FOODS  AND  FOOD  PREPARATIONS 

If  very  large  quantities  of  water,  or  any  fluids  consisting  chiefly  of 
water,  are  imbibed  throughout  a  long  period,  they  tend  to  overwork 
the  kidneys  and  produce  various  alterations  in  the  tissues.  Practi- 
cally, however,  it  seldom  happens,  excepting  in  some  forms  of  gas- 
tric or  intestinal  disorder,  and  other  instances  mentioned  above,  that 
too  much  water  is  taken.  When  drunk  in  such  fluids  as  beer,  or  di- 
luted liquors,  the  resulting  disturbances  of  the  system  are  attributable 
to  the  various  ingredients. 

The  role  of  water  in  Obesity  is  fully  discussed  under  that  topic. 

Deprivation  of  Water.  Water  Starvation. —  More  than  ten  or 
twelve  hours  of  abstention  from  drinking  water  produces  uncomfort- 
able thirst,  and  one  or  two  hours  of  violent  exercise  or  exposure  to 
intense  heat,  may  do  so  at  once. 

Continued  deprivation  of  water  causes  the  blood,  by  virtue  of  its 
self-regulating  power,  to  withhold  fluid  from  the  kidneys  and  diges- 
tive glands.  The  digestive  secretions  therefore  become  less  fluid, 
of  more  intense  reaction,  and  greatly  diminished  in  quantity.  The 
mucous  surfaces  become  dry,  and  the  dryness,  owing  to  the  passage 
of  air  and  the  consequent  evaporation,  is  first  felt  in  the  mouth  and 
pharynx.  The  diminution  in  the  digestive  secretions,  as  well  as  their 
altered  strength,  interferes  with  or  retards  their  normal  action  upon 
the  ingesta.  The  proper  movement  of  the  food  in  the  stomach  and 
intestines  is  retarded  by  its  greater  density  and  by  the  increased  fric- 
tion of  the  mucous  walls,  especially  in  the  lower  bowel.  Consti- 
pation therefore  results.  The  absorption  of  fluid  through  the  walls 
of  the  alimentary  canal  is  lessened,  and  nutrition  suffers  in  conse- 
quence. Meanwhile  the  blood,  to  maintain  its  normal  character,  re- 
absorbs  water  from  the  lymph  spaces  and  different  tissues  of  the 
body.  The  muscles  and  other  structures  become  dry  and  diminish 
in  volume.  Emaciation  results,  which  quickly  reaches  an  extraordi- 
nary and  painful  degree.  The  mind  dwells  on  water  constantly,  and 
taste  is  diminished.  Finally,  the  nervous  system  suffers  from  dry- 
ness  and  various  nervous  symptoms  ensue,  so  that,  in  addition  to 
extreme  muscular  weakness  and  prostration,  there  may  be  convul- 
sions, maniacal  delirium,  and  finally  ccma  and  death. 

TJrirst. — The  suffering  from  deprivation  of  water  is  mainly  con- 
fined to  the  sensations  of  thirst  and  dryness  of  the  mouth.  Thirst  is 
commonly,  and  somewhat  erroneously,  referred  to  the  mouth  and  the 
pharynx.  Tt  is  true  that  the  mucous  membrane  in  these  regions  be- 
comes dry  when  water  is  withheld,  but  thirst  also  may  be  keen  when 
these  surfaces  are  abundantly  moist.  The  sensation  is  the  result 
chiefly  of  the  expression  through  the  nervous  system  of  the  need  of  the 


WATER  43 

body  tissues  in  general  for  fluid,  and  it  is  referred  to  the  mouth  and 
throat  from  force  of  habit,  which  associates  the  act  of  swallowing 
fluid,  and  the  use  of  certain  muscles  in  that  process,  with  the  subse- 
quent relief  of  thirst.  In  support  of  the  above  statement  is  a  fact 
that  I  have  several  times  witnessed  in  patients  having  a  gastric  fistula 
made  in  consequence  of  cesophageal  stenosis,  or  in  patients  nourished 
wholly  through  nutrient  enemata,  that  the  sensation  of  thirst  referred 
by  them  to  the  mouth  is  immediately  relieved  by  the  injection  of  water 
into  the  stomach  through  the  fistula,  or  of  salt  and  water  into  the 
rectum. 

It  is  asserted  that  shipwrecked  sailors  in  open  boats  have  relieved 
their  thirst  by  immersing  their  bodies  in  salt  water.  A  very  little 
water  is  possibly  absorbed  under  these  conditions  through  the  skin. 
Ordinarily,  however,  the  skin  is  not  capable  of  absorbing  fluid  of 
any  kind  to  a  practical  extent,  but  immersion  in  water  prevents 
evaporation  from  the  surface  of  the  body,  and  by  saving  its  loss  in 
that  direction  lessens  thirst.  Sucking  a  slice  of  lemon  or  drinking 
water  acidulated  with  a  few  drops  of  lemon  juice  or  vinegar  some- 
times allays  thirst  better  than  plain  water.  The  same  may  be  said 
of  barley  and  oatmeal  waters,  often  used  by  laborers  when  sweating 
heavily.  Lime  juice  with  ice  is  another  remedy. 

On  one  of  the  earlier  arctic  expeditions  which  resulted  disastrously 
the  men  had  no  water  for  two  months,  but  ate  snow,  having  no  fuel 
to  spare  to  melt  it. 

Hot  water,  as  hot  as  can  be  sipped,  may  quench  thirst  better  than 
cold. 

Glycerin  and  water  is  sometimes  used  to  allay  thirst  by  rinsing  the 
mouth.  The  glycerin,  being  viscid,  coats  the  surface  of  the  mucous 
membrane  and  prevents  to  some  extent  the  drying  by  evaporation, 
but  it  is  hygroscopic  and  tends  to  abstract  water  if  used  too  strong, 
and  practically  it  is  of  little  service. 

When  it  is  undesirable  to  give  water  by  the  mouth,  as  in  gastric 
hemorrhage,  thirst  may  be  relieved  by  injection  of  salt  and  water 
beneath  the  skin  (see  Hypodermoclysis)  or  into  the  rectum. 

Thirst  may  be  controlled  somewhat  when  it  is  desirable  to  restrict 
the  fluids  ingested  by  giving  small  doses  of  opium.  It  may  be  that 
part  of  the  benefit  derived  from  this  drug  in  the  treatment  of  diabetes 
is  due  to  its  controlling  this  symptom.  It  is  taken  sometimes  by  pro- 
fessional fasters,  who  aim  to  abstain  from  all  food,  and  from  as  much 
drink  as  possible. 

When  it  is  desirable  for  patients  having  diabetes  mellitus  or  in- 
sipidus,  dropsies,  or  a  dilated  stomach,  to  have  the  fluid  ingested  re- 


44          FOODS  AND  POOD  PREPABATIONS 

stricted,  they  should  be  allowed  to  drink  only  from  very  small  re- 
ceptacles, like  a  medicine  glass,  which  holds  little  at  a  time,  or 
they  may  be  made  to  drink  only  through  a  small  glass  tube  or  straw. 

Temperature  of  Drinking  Water. —  Water  is  drunk  at  various  tem- 
peratures from  that  of  melting  ice  to  110°  or  112°  F.  It  is  some- 
times stated  that  the  temperature  of  water  influences  digestion,  but 
the  extent  to  which  it  does  so  is  much  exaggerated.  Very  cold  water 
swallowed  quickly  in  large  quantity  is  said  to  contract  the  stomach 
wall  and  stimulate  the  heart  action.  This  subject,  as  well  as  that 
of  the  local  action  of  hot  water,  will  be  found  more  fully  discussed 
under  the  heading  Temperature  and  Digestion. 

Ice  is  often  useful  in  the  sick-room,  but  it  should  not  be  given  to 
young  infants.  Cracked  ice  sometimes  soothes  an  inflamed  throat, 
and  occasionally  it  allays  nausea.  It  relieves  thirst  only  temporarily, 
and  this  symptom  may  be  increased  by  its  prolonged  use.  When  swal- 
lowed in  fragments  it  melts  almost  completely  before  reaching  the 
stomach,  and  if  too  much  is  swallowed  it  becomes  lukewarm  in  the 
stomach  and  may  be  vomited. 

Ice  is  frequently  contaminated  in  handling,  by  the  men  and  horses 
employed  in  harvesting  it,  and  surface  filth  from  drainage  may  pollute 
it.  Fortunately  exposure  of  a  few  weeks  to  a  freezing  temperature 
either  kills  most  noxious  germs  or  so  attenuates  them  as  to  nullify 
their  virulence. 


II.  SALTS 

Varieties  of  Salts. —  The  principal  salts  derived  from  the  food 
are  as  follows: 

Chlorides  of  sodium  and  potassium ;  carbonates,  sulphates  and  phos- 
phates of  sodium,  potassium,  and  magnesium,  and  phosphate  of  cal- 
cium. The  majority  of  these  salts  are  unaltered  by  digestive  pro- 
cesses and  pass  into  the  blood  or  tissues  without  necessary  chemical 
change.  The  reason  for  this  belief  is  the  readiness  with  which  they 
may  be  obtained,  unaltered  by  chemical  analysis,  from  the  different 
tissues  of  the  body  and  the  urine.  Some  compounds  —  namely,  the 
salts  of  iron  and  salts  of  the  organic  acids  —  are  ingested  in  very 
minute  quantity  and  the  uses  of  the  latter  are  vaguely  understood. 
Other  salts,  such  as  the  chlorides,  carbonates,  and  phosphates  of  the 
alkalies  and  alkaline  earths,  are  taken  in  much  larger  daily  amount 
and  subserve  definite  purposes. 

Uses  of  Salts  in  Food. —  The  uses  of  the  salts  derived  from  the  food 
are  summarized  as  follows: 


SALTS  45 

I.  To  regulate  the  specific  gravity  of  the  blood  and  other  fluids 
of  the  body. 

II.  To  regulate  the  chemical  reaction  of  the  blood  and  the  various 
secretions  and  excretions. 

III.  To  preserve  the  tissues  from  disorganization  and  putrefaction. 

IV.  To  control  the  rate  of  absorption  by  osmosis. 

V.  To  enter  into  the  permanent  composition  of  certain  structures, 
especially  the  bones  and  teeth. 

VI.  To  enable  the  blood  to  hold  certain  materials  in  solution. 

VII.  To  serve  special  purposes,  such,  for  example,  as  the  influ- 
ence of  sodium  chloride  on  hydrochloric-acid  formation,  that  of  lime 
salts  in  favoring  coagulation  of  the  blood,  and  that  of  iron  in  the 
formation  of  blood  pigment. 

Generally  speaking,  fruits  and  nuts  contain  the  least  quantity  of 
salts,  meats  rank  next,  after  them  vegetables,  and  pulses  and  cereals 
contain  most  of  all. 

Excess  of  Salt. —  Salts  of  any  kind  when  added  in  excess  to  the 
food  disagree  with  digestion  in  various  ways.  They  may  prove  lo- 
cally irritant  to  the  gastric  or  intestinal  mucous  membrane;  they 
modify  the  rate  of  absorption  of  digestive  material,  and  alter  the 
intensity  of  reaction  of  the  different  digestive  fluids.  After  being 
absorbed  in  excess  they  may  interfere  with  the  nutritive  and  chem- 
ical processes  of  the  blood  and  tissues.  Some  persons  acquire  a  salt- 
eating  habit  and  partake  too  freely  of  common  salt  with  the  food, 
eating  several  drachms  daily,  with  the  result  of  the  production  of  more 
or  less  dyspepsia  or  some  of  the  symptoms  above  mentioned.  Too 
much  sodium  chloride  in  the  food  produces  thirst,  and  may  stim- 
ulate a  craving  for  strong  drink. 

Lime  salts  and  phosphates  when  taken  in  food  or  drinking  water 
in  large  quantities  for  several  months  tend  to  cause  the  deposit  of 
renal  or  vesical  calculi. 

Deprivation  of  Salt. —  Continued  deprivation  of  any  one  of  the 
common  salts,  so  long  as  others  are  furnished  in  reasonable  abun- 
dance in  the  food,  does  not  result  seriously.  If,  however,  all  the  salts 
are  reduced  in  quantity,  or  if  they  are  entirely  excluded  from  the  diet, 
the  system  very  soon  begins  to  evince  signs  of  malnutrition.  This  is 
readily  accounted  for  by  referring  to  the  uses  of  salts  above  described. 
Animals  or  men  deprived  of  common  salt  for  a  long  time  suffer 
greatly  from  indigestion  and  from  lack  of  bodily  nutrition.  The 
body  may  not  diminish  in  weight,  but  the  tissues  become  "  flabby," 
the  muscles  feeble,  the  mind  is  stupid  and  dull,  the  nutrition  of  the 
skin  is  altered,  it  becomes  dry,  and  there  is  falling  out  of  the  hair. 


46  FOODS  AND  FOOD  PREPARATIONS 

Eventually,  in  animals  with  salt  starvation  death  occurs  in  from  six 
to  eight  weeks  from  progressive  bodily  weakness  and  inanition  —  a 
condition,  practically,  of  marasmus. 

Young  infants  who  do  not  obtain  sufficient  salts  of  lime  —  i.  e.,  if 
fed  upon  proprietary  "  infant  foods  "  instead  of  good  milk  —  become 
rhachitic;  their  bones  ossify  slo\dy  and  bend  into  deformities.  Such 
children  are  sometimes  given  hypophosphite-of-lime  biscuits  to  sup- 
ply the  deficiency,  but  they  should  be  properly  fed  upon  fresh  milk. 
(See  Eachitis.) 

Sodium  Chloride. —  Sodium  chloride,  or  common  table  salt,  is  by 
far  the  most  important  and  valuable  salt,  and  is  used  in  the  largest 
amount.  It  has  long  been  a  symbol  of  hospitality  in  the  East.  It 
forms  60  per  cent  of  the  salts  of  the  blood,  and  enters  into  the  struc- 
tural formation  of  all  the  tissues  and  secretions  of  the  body  in  greater 
or  less  quantity,  with  the  single  exception  of  the  enamel  of  the  teeth. 
It  is  estimated  that  the  quantity  which  may  be  appropriated  daily 
from  the  food  is  about  fifteen  grams  (231  grains).  Common  salt 
slightly  stimulates  the  renal  secretion,  which  in  turn  leads  to  thirst 
and  to  drinking  more  fluid,  which  promotes  interchange  of  the  juices 
of  the  body.  It  also  excites  thirst  more  directly. 

Common  salt  stimulates  the  appetite  and  influences  beneficially 
the  gastric  secretion.  It  not  only  furnishes  the  chlorine  for  hydro- 
chloric acid,  but  seems  to  act  locally  in  the  stomach  by  promoting 
this  secretion  as  well  as  the  conversion  of  pepsinogen  into  active 
pepsin.  Cohn  and  Voit  have  proved  that  the  absence  of  salt  from 
the  diet  completely  checks  the  production  of  hydrochloric  acid  in  the 
stomach. 

There  are  some  few  tribes  of  flesh-eating  man  who  do  not  add 
salt  to  their  food,  relying  for  their  needs  upon  what  they  derive 
from  the  food  itself.  This  supply  is  therefore  sufficient  to  maintain 
life.  In  fact,  as  a  rule,  man  derives  enough  salts  from  the  compo- 
sition of  his  food  to  supply  the  tissues  and  juices  of  the  body,  and 
the  additional  quantity  which  he  takes  as  table  salt  is  mainly  of  serv- 
ice as  a  condiment,  to  give  agreeable  flavor  to  a  mixed  diet  and  to 
sharpen  the  appetite.  The  excess  of  salts  in  general  is  promptly 
eliminated  in  the  urine. 

In  most  men  and  many  of  the  higher  mammalia  the  craving  for 
sodium  chloride  is  instinctive.  Stanley  records  in  his  book  "  In 
Darkest  Africa  "  instances  wherein  savages  were  accustomed  to  travel 
many  hundred  of  miles  under  great  difficulties  to  obtain  a  coveted 
supply  of  salt. 

Herbivorous  animals  are  even  more  dependent  upon  salt  than  are 


SALTS  47 

carnivores;  cattle  and  sheep,  for  example,  should  be  given  salt  in  ad- 
dition to  that  contained  in  their  food  to  remain  in  good  condition. 

Overdoses  of  salt  cause  diarrhoea  and  gastroenteritis,  and  excite 
irritation  of  the  nerves  of  the  throat.  Large  doses  of  salt  have  been 
given  in  pleurisy  with  the  view  of  increasing  the  density  of  the  blood 
and  causing  reabsorption  of  the  pleuritic  fluid  by  promoting  osmosis 
towards  the  vessels.  This  treatment  has  not  met  with  success  and  is 
the  reverse  of  the  salt  free  diet  described  below.  The  popular  use  of 
salt  to  control  pulmonary  hemorrhage  is  of  no  practical  value. 

Almost  all  vegetables  contain  less  sodium  chloride  than  does  milk, 
the  food  of  the  young  growing  animal,  although  many  of  them  have 
more  potassium. 

Sodium  chloride  is  of  great  service  as  a  preservative  of  foods, 
either  used  as  a  brine  in  pickling,  corning  beef,  preserving  olives,  etc., 
or  in  solid  form  to  dry  and  keep  meat  and  fish  from  decomposition. 
(See  Food  Preservation.) 

Salt-free  Diet. — Eecently  much  attention  has  been  directed  to  the 
use  of  a  salt-free  diet,  i.  e.,  food  to  which  no  salt  whatever  is  added, 
in  the  treatment  of  ascites  and  general  anasarca.  This  is  based  upon 
the  theory  that  the  absence  of  salt  modifies  the  density  of  the  blood 
so  that  osmotic  currents  are  reversed  and  the  serum  which  has  trans- 
uded into  the  tissues  is  reabsorbed  and  removed  by  the  blood  vessels 
or  lymphatics.  Such  a  diet  may  consist  of  raw  or  boiled  eggs,  milk, 
bread  made  without  salt,  cream  or  butter,  and  rice.  George  L.  Pea- 
body  has  reported  a  number  of  cases  of  general  anasarca  and  dropsy 
which  yielded  promptly  to  this  treatment  after  the  ordinary  means 
of  purgation,  diuresis,  diaphoresis,  etc.,  had  failed.  Personally  I  have 
found  it  disappointing  in  many  such  cases,  but  it  can  do  no  harm 
when  employed  for  short  periods  only.  One  patient,  with  severe 
chronic  nephritis  and  oedema  of  the  legs,  who  seemed  much  benefited  by 
it,  stated  that  for  a  week  he  greatly  missed  the  salt  which  he  had  been 
accustomed  to  add  liberally  to  his  food,  but  subsequently  his  sense  of 
taste  became  much  more  discriminating,  and  he  much  preferred  his 
salt-free  diet. 

Potassium  Salts. —  Xext  in  importance  to  sodium  chloride  ranks 
potassium  chloride,  which  is  the  predominant  salt  of  the  muscles,  and 
which,  like  sodium  chloride,  is  a  common  ingredient  of  nearly  all  the 
tissues  and  fluids.  The  acid  and  neutral  carbonates  and  phosphates 
of  sodium  and  potassium  are  important  in  regulating  the  reaction 
of  the  digestive  secretions  and  the  urine. 

Calcium. —  The  salts  of  calcium  are  chiefly  of  value  from  their 
constituting  a  large  percentage  of  the  composition  of  the  bones  and 


48  FOODS  AND  FOOD  PREPARATIONS 

teeth,  as  well  as  a  smaller  percentage  of  many  other  tissues  of  the 
body.  Their  presence  seems  to  be  associated  constantly  with  cell 
growth  and  development,  and  with  blood  coagulation.  The  carbonate 
is  often  found  with  the  phosphate  of  lime,  but  in  less  quantity.  The 
occurrence  of  cretinism  and  goiter  has  been  in  part  attributed  to  an 
excess  of  lime  salts  in  the  food,  more  especially  the  drinking  water. 
This  theory  is  referred  to  upon  page  38  as  unworthy  of  credence. 

Young  growing  animals  contain  in  their  tissues  a  larger  percentage 
of  earthy  salts  than  do  older  ones.  Deposits  of  salts  of  lime  occur  in 
old  abscesses,  tubercular  concretions,  tartar  on  the  teeth,  atheromatous 
blood  vessels,  the  arcus  senilis  of  the  cornea,  and  as  calculi. 

Medicinally  calcium  chloride  is  employed  to  promote  coagulation 
of  the  blood  in  purpura,  haemophilia,  etc. 

Phosphorus. —  Phosphorus  is  derived  from  phosphates  in  meat  and 
its  contained  blood  which  is  eaten,  as  well  as  from  vegetables.  It 
enters  into  the  composition  of  the  bones,  muscles,  blood,  etc. 

Sulphur. —  Sulphur  is  derived  from  sulphates  contained  princi- 
pally in  fibrin,  egg  albumen,  the  casein  of  milk,  and  from  such  vege- 
tables as  corn,  turnips,  cauliflower,  and  asparagus. 

Iron. —  The  iron  of  the  body  is  found  in  the  blood  pigment,  where 
it  amounts,  all  told,  to  a  third  of  an  ounce.  It  is  also  present  in 
minute  traces  in  other  pigments. 

Its  chief  source  is  from  the  blood  of  animals  which  is  cooked  with 
their  meat.  Two  quarts  of  milk  furnish  about  one-eleventh  grain  of 
iron.  It  is  also  derived  from,  and  it  may  be  taken  with,  chalybeate 
waters.  Probably  most  of  the  iron  of  the  body  is  retained  and  used 
again  and  again.  The  daily  quantity  of  iron  ingested  with  an  ordi- 
nary mixed  diet  is  about  one-eighth  grain.  In  treating  chlorosis  and 
other  forms  of  anaemia  with  large  doses  of  iron  salts,  it  should  be 
remembered  that  the  iron  contained  in  animal  foods  is  ample  for  the 
needs  of  the  body  in  health. 

VEGETABLE   ACIDS 

The  common  organic  or  vegetable  acids  —  citric,  tartaric,  malic, 
etc. —  are  derived  from  fresh  vegetables  and  fruits,  in  which  they 
exist  usually  in  combination  with  the  bases  Ca,  Na,  K,  etc.  They  are 
indispensable  articles  of  food,  for  when  absorbed  they  form  carbon- 
ates, which  aid  in  maintaining  the  akalinity  of  the  blood.  Prolonged 
deprivation  of  them  may  result  in  the  condition  of  scurvy. 


ANIMAL  FOODS  49 

III.  ANIMAL  FOODS 

Animal  foods  contain  much  nutritive  matter  in  a  more  or  less  con- 
centrated form  which  exists  in  practically  the  same  chemical  combina- 
tion with  the  body  itself.  They  leave  comparatively  little  residue,  be- 
ing quite  thoroughly  digested.  They  are  agreeable  in  flavor,  and  hold 
salts,  including  iron,  which  are  of  special  value  in  the  system.  They 
are,  however,  inferior  to  carbohydrates  in  force  production  unless 
much  fat  be  incorporated  with  them. 

The  varieties  of  animal  foods  will  be  described  under  the  head- 
ings, milk,  eggs,  meat,  fish,  gelatin,  fats. 

Milk 

The  milk  of  several  animals,  such  as  cows,  goats,  asses,  mares, 
reindeer  and  camels,  may  be  used  for  food,  but  in  this  country  very  lit- 
tle other  than  cows'  milk  is  employed.  The  varieties  of  milk  differ 
slightly  in  chemical  composition,  odor,  and  taste,  but  all  contain  the 
elements  which  are  necessary  for  the  maintenance  of  life  in  fairly  eco- 
nomic proportion,  so  that  for  infants  they  constitute  a  "  complete  " 
food  which  fully  meets  the  requirements  of  the  growing  body,  and  in 
adults  they  will  sustain  life  comfortably  for  many  months. 

For  these  reasons  milk  ranks  among  the  most  important  of  all  foods, 
and  it  is  necessary  to  determine  to  what  extent  it  should  be  intro- 
duced into  ordinary  diet.  A  pint  of  milk  may  be  said  to  represent 
approximately  the  nutrition  contained  in  six  ounces  of  beef  or  mut- 
ton. Although  it  furnishes  so  useful  a  food,  milk  is  by  no  means 
essential  to  a  diet  designed  for  increasing  bodily  strength,  and  it  is 
usually  omitted  from  the  menu  of  athletes  in  active  training. 

Milk  taken  alone  constitutes  a  poorly  balanced  food  for  adults  in 
health,  for  to  obtain  the  requisite  18.3  grams  of  nitrogen  2,905  grams 
of  milk  only  are  needed,  against  4,652  which  must  be  taken  to  obtain 
the  necessary  328.9  grams  of  carbon  (Bauer).  (See  Force  Produc- 
tion, page  6.) 

Sir  Henry  Thompson,  in  condemning  the  excessive  drinking  of 
milk  by  persons  in  health  who  are  at  the  same  time  eating  large 
meals  of  meat,  says:  "It  is  altogether  superfluous  and  mostly  mis- 
chievous as  a  drink  for  those  who  have  reached  adult  age  and  can 
digest  solid  food."  There  are,  however,  many  diseases  in  which  a 
partial,  or  for  a  time  an  exclusive,  milk  diet  is  to  be  recommended,  and 
milk  in  considerable  quantity  —  i.  e.,  equal  to  one-third  or  one-half 
the  total  amount  of  food  consumed  —  is  often  highly  desirable  in  such 
diseases  as  tuberculosis,  chronic  Bright's  disease,  and  anaemia. 


50  FOODS  AND  FOOD  PREPARATIONS 

Exclusive  Milk  Diet. —  An  exclusive  milk  diet  is  useful  in  the  fol- 
lowing conditions  and  diseases. 

1.  In  infancy  for  the  first  year,  and  sometimes  for  the  first 
eighteen  months.  2.  All  acute  infectious  diseases  of  young  children. 
3.  Typhoid  fever.  4.  Acute  Bright's  disease,  and  at  times  in 
chronic  nephritis.  5 :  Acute  pyelitis.  6.  Chronic  gastric  catarrh 
(some  cases).  7.  Gastric  ulcer  and  carcinoma  (at  certain  stages). 
8.  Neurasthenia  combined'  with  a  rest  cure.  9.  Some  cases  of  dia- 
betes. 

A  milk  diet  is  so  easy  to  prescribe,  so  cheap,  and  so  readily  pro- 
curable, that  it  is  the  first  resource  of  those  who,  from  indifference  or 
lack  of  knowledge  of  the  first  principles  of  dietetics,  are  unwilling 
or  unable  to  study  the  peculiarities  and  needs  of  the  individual 
patient.  It  is  an  easily  measured  food,  and  it  becomes  a  routine  prac- 
tice in  hospitals  —  where  almost  always  more  attention  is  accorded 
to  medication  than  to  diet  —  to  order  "milk  diet"  for  all  patients 
who  are  not  at  the  convalescent  or  full  house  table.  Although  it  is 
safe  to  err  in  this  direction,  it  is  by  no  means  always  the  best  that 
can  be  done  for  the  patients. 

An  exclusive  milk  diet  in  time  becomes  wearisome  to  many  adults, 
and  within  a  week  or  ten  days  may  produce  dyspepsia,  constipation, 
and  interfere  with  the  functional  activity  of  the  liver.  Aside  from 
nausea,  which  the  continued  use  of  milk  may  excite,  a  positive  loath- 
ing for  the  taste  of  it  may  be  developed,  unless  the  regimen  is 
modified  by  occasional  variation.  This  is  a  matter  of  considerable 
importance  in  feeding  patients  suffering  from  typhoid  fever,  chronic 
Bright's  disease,  chronic  gastric  catarrh,  and  other  affections  for 
which  milk  diet  is  often  prescribed;  for  if  other  substances  are  sub- 
stituted from  time  to  time  in  small  amounts,  while  milk  is  still  re- 
tained as  the  chief  food,  it  may  be  continued  as  such  for  a  much 
longer  time.  On  seeking  the  cause  for  the  disagreement  of  milk,  it 
is  found  in  the  fact  that  it  contains  too  large  a  proportion  of  protein 
as  compared  with  carbohydrate,  so  that,  in  order  to  obtain  sufficient 
of  the  latter,  an  excess  of  protein  is  ingested,  which  may  derange 
digestion. 

For  a  man  in  health  a  pure  milk  diet,  as  Ewald  says,  is  "  slow 
starvation,"  although  it  is  an  excellent  food  for  a  short  time.  If  kept 
ton  long  upon  it,  lie  develops  a  condition  akin  to  scurvy.  (See 
Diet  in  Scurvy.)  Tin's,  however,  does  not  invariably  follow  in 
disease,  and  J.  K.  Mitchell  refers  to  a  patient  with  diabetes  and 
nephritis  "who  lived  upon  milk  alone  for  seven  years,  and  kept  in 
active  business. 


ANIMAL  FOODS  51 

Infants  and  children  tire  of  milk  less  promptly  than  adults. 
Whereas  the  adult  needs  twenty-three  ounces  of  water-free  food  per 
diem  to  maintain  healthful  equilibrium,  he  must  consume  nine  pints 
of  milk  to  supply  it.  The  excess  of  albumin,  fat,  and  water  which 
he  would  then  obtain  is  wasteful  for  him,  although  it  is  good  for 
the  young.  But  in  illness  life  is  comfortably  maintained  upon  a 
smaller  quantity  of  milk  for  a  few  weeks,  and  in  typhoid  fever 
four  or  five  pints  is  an  ample  allowance,  and  it  is  often  better  to 
give  less.  (See  Diet  in  Typhoid  Fever.)  In  a  case  of  chronic 
Bright's  disease,  if  the  patient  be  not  confined  to  bed,  it  may  be 
necessary  to  give  six  or  seven  pints. 

In  order  to  digest  thoroughly  large  quantities  of  milk  it  should  be 
taken  in  measured  doses  at  frequent  intervals.  In  some  diseases  it  is 
best  to  give  two  ounces  every  hour,  in  others  six  or  eight  ounces  every 
three  hours. 

Milk  leaves  no  coarse  waste  residue  in  the  intestine  like  the  indi- 
gestible fiber  of  meat  or  the  cellulose  of  vegetables  and  fruits.  Not- 
withstanding this  fact,  an  exclusive  milk  diet  yields  considerable  bulk 
of  fecal  matter,  and  a  typhoid-fever  patient  living  on  milk  alone  often 
has  daily  evacuations  of  medium  size.  0.  Riibner  found  that  in  health 
a  diet  of  milk  alone  yields  larger  stools  than  either  roast  beef  or  egg 
alone.  Yet  by  weight  the  absorption  of  milk  is  shown  to  be  very 
complete,  and  four  thousand  grams  of  milk  ingested  by  the  mouth, 
when  perfectly  digested,  yield  only  one  hundred  grams  of  feces. 
There  is  a  marked  loss  through  the  feces  of  the  salts  of  lime  which 
have  been  contained  in  the  milk.  These  facts  explain  in  part  why 
milk  is  so  constipating. 

Prof.  Charles  E.  Wait,  in  the  course  of  nutrition  investigations 
of  a  club  of  students  at  the  University  of  Tennessee  (U.  S.  Depart- 
ment of  Agriculture  Bulletin),  says: 

"  The  average  of  ten  experiments  with  an  exclusive  milk  diet 
showed  92.1  per  cent  of  the  protein  and  86.3  per  cent  of  the  carbo- 
hydrates to  be  digested.  Five  experiments  made  with  an  exclusive 
bread  diet  or  with  bread  and  sugar  showed  82  per  cent  of  the  protein 
and  99  per  cent  of  the  carbohydrates  to  be  digested.  Five  experi- 
ments with  a  diet  of  bread  and  milk  showed  97.1  per  cent  of  the 
protein  and  98.7  per  cent  of  the  carbohydrates  to  be  digested.  In 
other  words,  the  protein  in  milk  alone  or  in  bread  alone  seems  to 
be  much  less  completely  digested  than  when  the  two  are  eaten 
together."  (See  the  "Milk  Cure.") 

Physical  Properties  of  Milk. —  The  milk  of  all  animals  as  well  as 
human  milk  is  alike  as  regards  its  general  physical  properties  and 


52 


FOODS  AND  FOOD  PREPARATIONS 


the  nature  of  its  chemical  components,  differing  only  in  degree.  The 
solids  of  milk  exist  (a)  in  soluble  form  (salts  and  sugar)  (b)  in 
suspension  (fat  globules)  (c)  in  semi-solid  or  colloidal  state  (part 
of  the  casein). 

The  specific  gravity  of  cow's  milk  varies  between  1029  and  1035, 
the  normal  average  being  1032  at  60°  F.  An  excess  of  cream  makes 
the  milk  lighter.  If  the  cream  be  partially  removed  and  water  be 
added,  the  gravity  is  raised,  hence  the  specific  gravity  alone  is  not 
an  infallible  test  for  the  richness  of  milk. 

The  reaction  of  normal  fresh  cow's  milk  is  always  slightly  acid, 
owing  to  the  presence  of  acid  phosphates.  Casein  has  an  acid  reac- 
tion also,  and  C02  may  be  present  and  affect  the  reaction.  Lactic 
acid  fermentation  increases  the  acidity  of  milk  and  the  greater  the 
number  of  bacteria  present  in  the  milk,  the  greater  the  acidity.  The 
acid  reaction  is  stronger  in  summer  than  in  winter. 

Chemical  Composition  of  Milk. —  The  chemical  ingredients  which 
make  milk  valuable  as  a  food  are  water,  salts,  fats,  milk  sugar 
or  lactose,  and  albuminoids,  chiefly  casein,  with  some  albumin. 
The  following  table  prepared  by  E.  H.  Farrington  and  F.  W.  Woll 
exhibits  "  the  limits  within  which  the  components  of  normal 
American  cow's  milk  are  likely  to  come."  The  figures  are  percent- 
ages: 


\Vater           

Minimum. 
82  0 

Maximum. 
90  0 

Average. 
87  4 

Fat   

2  5 

7  8 

3  5 

Casein  and  ulbuiiiin    .  .    .  .         

2  5 

4  6 

3  4 

Lactose    

3  5 

6  0 

5  0 

Ash                     .              

g 

q 

7 

100.0 

Babcock's  table  of  average  percentage  analysis  of  American  milk  is 

very  similar : 


Water     87.17 

Fat   3.G9 

Casein    .  .3.02 


Albumin    53 

Lactose    ' 4 . 88 

Ash  .71 


The  following  table  is  from  the  U.  S.  Department  of  Agriculture, 
Farmers'  Bulletin. 


ANIMAL  FOODS 


53 


Amounts  of  Nutrients  in  a  Pound   (Pint)  of  Milk  as  Compared  with  a  Pound 
of  Meat,  Bread,  and  Other  Food  Products. 


EDIBLE  PORTION. 


FOOD  MATERIALS. 

Water. 

NUTRIENTS. 

Fuel 

value. 

Protein. 

Fat. 

Carbo- 
hydrates. 

Minera 
matter. 

Milk    (1   pint.) 
Whole  milk    

Pound. 

0.87 

0.90 
0.91 

0.34 
0.11 
0.53 
0.43 

0.44 
0.35 
0.07 
0.48 

0.58 
0.40 
0.38 
0.88 
0.12 
0.13 
0.07 
0.35 
0.08 
0.13 
0.70 
0.67 
0.62 
0.62 

Pound. 
0.03 

0.04 
0.03 

0.26 
0.01 
0.16 
0.13 

0.14 
0.13 
0.02 
0.15 

0.11 
0.16 
0.17 
0.06 
0.11 
0.09 
0.16 
0.10 
0.11 
0.22 
0.01 
0.02 
0.01 
0.01 

Pound. 

0.04 

o.'oi 

0.34 
0.85 
0.17 
0.24 

0.25 
0.34 
0.87 
0.01 

o.ii 

0.02 
0.01 
0.02 
0.07 
0.01 
0.10 
0.02 

Pound. 
0.05 

0.05 
0.05 

0.02 

6!03 
0.75 
0.75 
0.68 
0.53 
0.69 
0.59 
0.08 
0.15 
0.06 
0.12 

Pound. 

0.01 

0.01 
0.01 

0.04 
0.03 
0.01 
0.01 

0.01 
0.04 
0.04 
0.01 

0.01 
0.19 
0.10 
0.01 
0.01 
0.01 
0.02 
0.01 
0.02 
0.04 
0.01 
0.01 
0.01 

Calories. 

325 

170 
165 

1,965 
3,605 
1,040 

1,275 

1,340 
1,655 
3,715 
325 

205 
315 
1,050 
235 
1,645 
1,655 
1,860 
1,205 
1,895 
1,590 
170 
325 
135 
255 

Skim    milk    (0.3    per   cent 
f  at  )  .   .  .  .  •  

Buttermilk    

Other  food  materials 
(1  pound  each). 

Cheese    

Butter    

Beef,    sirloin     

Mutton,   side    

Pork: 
Loin    

Ham 

Salt,   fat    

Chicken    

Codfish  : 
Fresh    

Salt    

Mackerel,  salt    

Oysters,  solids   

Wheat  flour    

Cornmeal   

Oatmeal   

Wheat  bread    

Crackers    

Dried   beans    

Beets    

Potatoes  

Turnips    

Apples    

"  The  fuel  value  of  a  pint  of  cream  is  not  far  from  1,425  calories, 
or  about  the  same  as  one  and  one-eighth  pound  of  bread,  or  one 
and  one-half  dozen  bananas,  or  four  and  one-half  pounds  of  potatoes." 

Water  constitutes  from  82  to  90  per  cent  of  milk.  In  17  States 
the  legal  maximum  for  salable  milk  is  fixed  at  88  per  cent. 

Frozen  Milk. —  When  milk  freezes  the  water  crystallizes  into  lumps 
of  ice  containing  a  trace  of  fat  and  other  solids  of  the  milk. 

The  salts  which  form  the  "  ash  '"'  of  milk  after  incineration  are 
principally  chlorides  of  sodium  and  potassium,  and  phosphates  of 
potassium  calcium  and  magnesium.  There  are  also  traces  of  iron 


54          FOODS  AND  FOOD  PREPARATIONS 

phosphate,  sulphuric  and  citric  acids,  lecithin,  cholesterin,  urea, 
hypozanthin,  a  coloring  matter  called  lactochrome  and  the  gases, 
oxygen,  nitrogen  and  carbonic-acid. 


Total  Solids. 


Water. 


Sugar. 


Fat. 


Casein.     Ash. 


FIG.  4. —  PROPORTION  OF  THE  COMPONENT  PARTS  OF  MILK. 
(R.  A.  Pearson,  U.  S.  Dept.  Agric.,  Farmers'  Bui.,  No.  42.) 


Fat  and 
Cream.— The  fat 
of  milk  exists  as 
an  emulsion,  and 
the  fat  globules 
are  exceedingly 
minute,  about 
100,000,000  be- 
ing contained  in 
an  average  drop 
of  milk.  The 
globules  vary 
much  in  size, 
both  according  to 
the  breed  of  the 
cow,  and  the  pe- 
riod of  lactation. 
The  largest  glob- 
ules are  observed 
at  the  beginning 
(U.  S.  TVpt.  Airrir..  Bui.  f)G,  Office  of  Expt.  Stations.)  °f  lactation,  and 


f>. —  A  DROP  OF  MM.K.  MAGNIFIED,  SHOWING  FAT 
GLOBULES. 


ANIMAL  FOODS 


55 


the  smallest  are  found  in  skimmed  milk.  The  measurements  of  the 
globules  show  a  range  in  diameter  between  1-1500  and  1-25,000  inch. 
The  analyses  of  milk  vary,  chiefly  in  regard  to  the  quantity  of  fats 
observed,  in  relation  to  the  other  solids.  The  following  analyses 
are  placed  together  for  comparison : 


Wanklyn. 

London  Dairy. 

J.  C.  Bell. 

A.H.Leeds. 

E.  W.  Stewart. 

Fat       

3.20 

4.10 

4  01 

3  75 

3  80 

Other  solids   .  .  . 

9  30 

8  80 

9  31 

8  86 

9  20 

Total  solids    .  .  . 
Water    

12.50 
87  50 

12.90 
87  10 

13.32 

86  68 

12.61 
87  39 

13.00 
87  00 

100.00 

100.00 

100.00 

100.00 

100.00 

The  above  London  Dairy  analysis  is  based  upon  the  examination 
of  120,000  samples  of  milk  conducted  by  the  chemist  to  the  dairy 
during  a  period  of  twelve  years. 

Milk  fat  is  mainly  formed  of  glycerides  of  palmitic  and  oleic  acid, 
with  several  other  fatty  acids,  represented  in  lesser  quantity. 

The  fatty  acids  of  milk  are  grouped  with  their  percentages  by 
Browne  as  follows: 

NOX-VOLATILE 

Palmitic  40.51 

Oleic   33.95 

Myristic     10.44 

Stearic    

Dioxystearic 1.04 


VOLATILE 


Butyric 
Tauric    . 
Caproic 
Caprylic 
Capric     . 


6.23 

2.73 

2.32 

.53 

.34 


100.00 

The  non-volatile  fats  exist  in  the  proportion  of  92  per  cent,  the 
volatile  8  per  cent. 

These  tabulated  figures  represent  averages  only,  computed  on  a 
large  scale,  for  Wing  states  that  "the  difference  in  the  percentage 
of  fat  in  milk  from  different  cows  of  the  same  breed  is  quite  as 
great  as  the  average  differences  between  the  breeds."  While  the 
average  percentage  of  fat  in  American  cow's  milk  is  about  4  per 
cent,  the  legal  standard  in  most  States  is  3  per  cent.  Cream  is  not 
pure  fat;  it  is  an  aggregation  of  the  oil  globules  in  the  top  portion 
of  the  milk  with  a  little  proteid  and  carbohydrate.  Cow's  milk  very 


56 


FOODS  AND  FOOD  PREPARATIONS 


rarely  reaches  as  high  a  percentage  of  fat  as  7,  and  there  are  few 
authenticated  analyses  above  that  figure. 

Average  cream  contains  (according  to  Farrington  and  Woll)   the 
following  percentages : 

Water     66.0 

Fat    25.4 

Casein   and   Albumin    3.8 

Lactose     4.3 

Ash    .  .5 


100.0 

The  skimmed  milk  after  removal  of  the  cream  by  a  separator 
contains  less  than  0.2  per  cent  of  fat,  or  if  obtained  by  gravitation 
in  a  pan,  0.4  per  cent.  Average  cow's  milk  contains  8  to  10  per 
cent  of  cream.  Alderney  milk  may  have  as  high  as  20  or  even  30  per 
cent.  Good  milk  should  form  a  layer  of  cream  about  two  inches 
and  a  half  thick  as  it  stands  in  a  quart  bottle.  An  average  yield 
of  cream  from  1,000  Ibs.  of  milk  is  145  Ibs.  from 
which  42  Ibs.  of  butter  may  be  obtained. 

Butter  fat  melts  at  92-96°  F.  The 
ordinary  hardness  of  butter  is  main- 
tained by  olein,  which  melts  at  41° 
F.  The  odor  and  flavor  of  butter, 
and  to  a  great  extent  of  milk,  is  due 
to  butyrin.  When  this  fat  decom- 
poses from  the  action  of  bacteria  and 
light,  it  forms  butyric  acid,  giving  a 
rancid  odor  and  flavor  to  butter. 

Various  volatile  oils  in  the  food 
of  the  cow  from  time  to  time  may 
be  present  in  the  milk,  modifying  its 

FH;.  o. —  CHAPMAN'S  DIPPER,  FOE  taste  and  odor,  for  example  those  de- 
REMOVING    TIIK    UPPEK    LAYERS  -,    ,,  ,,          ,,  .          .,, 

OF  MILK  (Holt).  rived  irom  the  cabbage,  turnip,  wild 

onion  or  garlic. 

Lactose. —  Lactose  is  an  important  ingredient  of  milk,  forming  33 
per  cont  of  its  total  solids.  It  is  used  also  commercially,  prepared 
from  whey,  as  an  ingredient  of  many  proprietary  infant  and  in- 
valid foods.  AVhen  chemically  pure  it  is  hard,  transparent,  white, 
and  crystalline.  It  is  now  obtainable  in  much  purer  commercial 
form  than  formerly,  when  in  addition  to  its  diuretic  effect,  if  given 
therapeutieally,  it  often  developed  irritation  and  even  glycosuria. 
It  is  loss  soluble  and  much  less  sweet  than  sucrose,  although  it  pos- 
sesses  the  same  chemical  formula.  Its  chief  function  in  human  milk  is 


ANIMAL  FOODS  57 

to  supply  energy  for  heat  production  for  the  infant  whose  muscles  are 
not  yet  active  in  developing  this  force.  The  quantity  present  in  cow's 
milk  varies  greatly,  and,  as  a  general  rule,  bears  an  inverse  ratio  to 
the  quantity  of  fat  and  casein  present.  It  is  less  liable  than  cane 
sugar  to  ferment  in  the  stomach;  and  alone  it  is  not  susceptible  to 
alcoholic  fermentation.  Certain  bacteria  feed  upon  milk  sugar,  con- 
verting it  into  lactic  acid,  making  the  milk  sour.  It  is  promptly 
absorbed  from  the  alimentary  canal,  not  remaining  over  an  hour  in  the 
stomach. 

Casein  and  Albumin. —  The  principal  albuminoid  of  milk  is  casein, 
or  caseinogen,  but  there  are  a  half  dozen  proteids  which  have  been 
described,  showing  different  behavior  on  coagulation,  in  polariscopic 
rotation,  etc.  There  are  albumins  present  called  lactoglobulin  and 
lactalbumin  or  lactoprotein,  which  latter  is  coagulable  at  170°  F., 
and  forms  the  tenacious  "  scum "  which  floats  on  top  of  boiled 
milk. 

Casein  constitutes  about  80  per  cent  of  the  total  nitrogenous 
bodies  in  milk.  It  exists  in  normal  cow's  milk  in  the  proportion  of 
2  to  4  per  cent,  and  albumin  is  present  in  .5  to  .8  per  cent.  Milk 
with  a  low  fat  percentage  may  therefore  contain  more  protein  (casein 
and  albumin)  than  fat. 

Casein  exists  in  milk  both  in  solution  and  largely  in  sus- 
pension in  a  colloidal  state,  associated  with  insoluble  calcium  phos- 
phate. In  the  colloidal  form  it  is  retained  when  milk  is  passed 
through  a  Chamberlain  porous  filter. 

Casein  is  non-coagulable  by  heat,  even  by  boiling,  but  is  coagu- 
lated in  firm  tough  clots  by  acids,  such  as  hydrochloric  acid  of 
the  gastric  juice,  and  by  many  organic  acids  which  occur  as  prod- 
ucts of  malfermentation  in  the  stomach.  Lactic  acid  is  the  com- 
mon agent  in  forming  the  coagulae.  Casein  is  also  coagulated,  but 
less  firmly,  by  the  special  milk-curdling  ferment  "rennin,"  in  the 
presence  of  soluble  calcium  salts.  This  ferment  is  present  in  the 
infant  stomach,  and  in  the  third  stomach  of  the  calf.  The  casein 
clot  formed  by  rennin,  unlike  that  of  lactic  acid,  is  not  redissolved 
by  neutralization  which  alkalies.  Dry  casein  is  used  commercially 
to  make  sizing  for  paper,  and  various  artificial  foods  are  made  with 
it  (see  Somatose). 

It  has  long  been  taught  that  the  casein  of  cow's  milk  was  more 
difficult  of  digestion  than  that  of  human  milk,  but  it  has  lately  been 
proved  by  Czerny,  Keller  and  0.  Huebner  that  this  is  an  error,  and 
the  supposed  undigested  "  curds  "  of  coagulated  casein  so  often  seen 
in  infant's  stools  are  really  masses  of  saponified  fat  with  fatty  acids, 


58 


FOODS  AND  FOOD  PREPARATIONS 


neutral  fat  and  bacteria.  Hence  it  is  more  often  the  fat  than 
the  casein  of  cow's  milk  which  disorders  infant  digestion. 

Other  proteid  substances  are  present  in  minute  quantities  in  milk. 
Such  are :  globulin,  nuclein  or  proteose  or  hemi-albumose,  and  fibrin. 

Milk  Ferments. —  The  ferments  nominally  present  in  milk  are 
weakened  or  destroyed  by  varying  degrees  of  temperature  as  shown 
in  the  following  table  by  Hippius  quoted  from  Roland  G.  Freeman. 

THE  EFFECT  OF  HEAT  ON  CERTAIN  BIOLOGIC  CHARACTERISTICS  OF  MILK  AS 
DETERMINED  BY  HIPPIUS. 

1.  Present  in  Woman's  Milk  and  not  present  in  Cow's  Milk. 

Unchanged    by       Weakened     by        Destroyed   by 
Salol-splittingferment 131°   F.     '  149.°  F. 

(  1   hr.  at   140°   F.      158°     F.     short  167°    F. 

Ainylolytic  ferment,      j  %  hri  &t  14J)0  F>  time 

2.  Present  in  "Woman's  Milk  and,  present  but  less  active  in  Cow's  Milk. 

Unchanged'  by       Weakened     by         Destroyed   by 
Fat-splitting   ferment.  143°   F.  145-°   F.  147°   F. 


3.     Active  in  both  Woman's  and  Cow's  Milk. 

Unchanged    by  Weakened     by        Destroyed   by 

Proteolytic  ferment,      i  1  hr.  140—149°  F Boiling. 

/  y2   hr.   at    149°  F. 

1    hr.    at    140°    F.  .    1  min.  at  169°  F. 


Oxidizing  ferment. 
Bactericidal  action. 


2min.  at  185°  F. 
Alexius    according    to  ,    ,,no  ^ 

STa-Sta! IftJESSP* 

•-'— • ^tartiff  J: 


Boiling. 
Boiling. 


This  table  also  shows  an  important  fact  determined  by  Spolverini, 
namely  that  the  milk  of  herbivores,  such  as  the  cow  and  goat,  lacks  the 
amylolytie  and  salol-splitting  ferments  observed  in  the  milk  of  omni- 
vores  such  as  woman  and  the  dog. 

Varieties  of  Milk. —  Cow's  milk  differs  in  quality  according  to 
the  breed  and  condition  of  the  animal,  nature  of  its  food,  and  care 
bestowed  upon  feeding  and  hygienic  surroundings.  The  chief  varia- 
tion concerns  the  quantity  of  fat.  The  milk  of  different  breeds  of 
cows  varies  so  much  in  richness  of  fat  and  other  ingredients  as  to 
be  a  matter  of  great  dietetic  importance  especially  in  regard  to  infant 
feeding.  The  following  table  compiled  by  Henry  H.  Wing  "from  a 
large  number  of  analyses  made  at  various  American  Agricultural 
Experiment  Stations''  illustrates  this  fact: 


ANIMAL  FOODS  59 

Solids.  Fat. 

Jersey     14.70  5.35 

Guernsey    . .  / 14.71  5.16 

Devon     14.50  4.60 

Short-horn     13.38  4.05 

Ayrshire     12.61  3.66 

Holstein-Fricsian   11.85  3.42 

The  milk  of  Alderney,  Jersey,  and  Guernsey  cows  has  more  pro- 
tein than  that  of  ordinary  animals,  and  Alderneys  give  more  fat 
than  Longhorns.  Individual  cows  are  liable  to  vary  both  among 
themselves  and  from  day  to  day  in  the  quality  of  their  milk,  and 
therefore,  notwithstanding  general  belief,  it  is  a  disadvantage  to  feed 
an  infant  always  upon  the  milk  of  the  same  cow.  More  uniformity 
on  the  average,  may  be  secured  by  feeding  the  mixed  milk  of  several 
animals,  the  variations  in  the  components  neutralizing  each  other. 

"  Strippings"  is  the  name  given  to  residual  milk  which  may  be 
drawn  off  shortly  after  the  ordinary  milking  has  been  completed. 
Contrary  to  popular  belief,  it  possesses  no  advantage  as  food  over  the 
rest  of  the  milk,  and  what  little  difference  in  composition  exists  may 
be  produced  artificially.  It  is  richer  in  fat  but  poorer  in  casein  than 
the  milk  first  drawn.  For  infant  use  it  should  be  diluted  with  two 
parts  of  water  to  one  of  milk. 

Human  Milk. —  Human  milk  differs  from  cow's  milk  in  several 
important  particulars.  For  this  reason  it  becomes  necessary  when 
infants  are  fed  upon  the  latter  to  so  modify  it  as  to  render  it  more 
digestible  for  them. 

The  essential  differences  between  human  milk  and  cow's  milk 
are  that  woman's  milk  is  sweeter  by  one-third  and  contains  little 
less  than  half  as  much  casein.  The  analyses  of  the  United  States 
Department  of  Agriculture  give  the  percentage  of  casein  in  cow's 
milk  as  varying  between  3.43  and  3.91,  whereas  that  of  mother's  milk 
averages  1.5,  hence  the  importance  of  diluting  cow's  milk  in  the  early 
months  of  infant  feeding.  As  Leeds  says,  the  calf  grows  faster 
and  has  to  manufacture  more  muscle  than  the  baby  —  it  needs  more 
albumin  for  tissue  building.  The  casein  of  mother's  milk,  moreover, 
forms  smaller  coagula?  in  the  stomach,  which  are  more  easily  dis- 
solved. The  reaction  of  human  milk  is  alkaline  to  litmus,  but  faintly 
acid  to  phenophthalin  (see  p.  64).  There  is  nearly  one-half  per 
cent  more  fat,  and  the  globules  exist  in  a  finer  emulsion  in  woman's 
than  in  cow's  milk.  In  cow's  milk  there  are  from  6  to  8  times 
as  much  of  the  fatty  acids,  butyric,  caproic,  capric  and  caprylic,  as 
in  human  milk.  Cow's  milk  appears  richer,  whiter,  and  more  opaque 
than  human  milk. 


60 


FOODS  AND  FOOD  PREPARATIONS 


These   differences   are   emphasized   by  the   following  comparative 
analyses  by  Leeds  of  average  cow's  milk  and  human  milk : 


Sound  dairy  milk. 

Human  milk. 

Feebly  acid. 

Alkaline,  (litmus) 

Specific    gravity                      

1029.7 

1031.3 

Bacteria/          .            

Always  present. 

Absent. 

Fats                  

3.75  per  cent. 

4.13  per  cent. 

4  42        " 

71           " 

Albuminoids        

3  76        " 

20           " 

Ash             

0  68        " 

02           " 

Total  solids    

12  61        " 

13  33        " 

It  requires  more  acid  to  precipitate  the  proteid  from  woman's 
milk  than  from  cow's  milk,  and  it  is  not  precipitated  in  large 
coaguke  by  rennin.  Giving  a  nursing  woman  an  excess  of  nitro- 
genous food  does  not  increase  the  albuminoid  elements  of  her 
milk  so  much  as  the  fats,  while  giving  fatty  or  rich  food  in  excess 
does  not  increase  the  cream  or  other  ingredients  of  her  milk  —  it  may, 
indeed,  diminish  them  by  disordering  her  digestion.  The  nursing 
mother's  diet  therefore  should  be  plain  but  substantial,  especially  in 
regard  to  animal  foods.  Excessive  fat  or  protein  in  the  mother's 
milk  disorders  the  infant's  digestion. 

The  following  analyses  illustrate  the  extent  of  possible  variation 
in  good  specimens  of  human  milk : 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

Fat  

Per  cent  _ 

4  37 

Percent. 

3  76 

Percent. 
3  16 

Percent. 

3  82 

Percent. 
2  96 

Percent. 
2  09 

Per  cent. 
2  02 

Percent. 
2  36 

Milk  sugar  .  .  . 
Albuminoids  .  . 
Mineral  matter 

6.30 
3.27 
0.16 

6.95 
2.04 
0.14 

7.20 
1.65 
0.21 

5.70 
1.08 
0.20 

5.78 
1.91 
0.12 

6.70 

1.38 
0.15 

6.55 
2.12 
0.15 

7.10 
2.20 
0.16 

Total  solids. 
Water  .... 

14.10 

85  90 

12.89 
87  11 

12.22 

87  78 

10.80 
89  20 

10.77 
89  23 

10.32 
89  68 

10.84 
89  16 

11.82 
88  18 

100.00 

100.00 

100.00 

100.00 

100.00 

100.00 

100.00 

100.00 

For  the  analysis  of  human  milk  about  half  an  ounce  is  required, 
drawn  from  the  middle  nursing  period,  for  the  milk  becomes  pro- 
gressively richer  during  nursing. 

Prof.  Albert  II.  Leeds  (American  Text-book  of  the  Diseases  of 
Children,  pp.  42,  43)  lias  shown,  by  a  table  of  analyses  of  milk  from 
eighty  women  of  different  nationalities,  ages,  and  periods  of  lactation, 
that  although  "  the  average  amount  of  nitrogenous  matters  [albumi- 


ANIMAL  FOODS  61 

noids]  is  somewhat  greater  at  beginning  of  lactation,  the  difference 
is  not  very  marked.  .  .  .  There  is  no  progressive  change  in  the 
composition  of  milk  during  lactation,  but  after  the  function  has  been 
normally  established  the  milk  remains  substantially  the  same  during 
the  entire  period.  .  .  .  The  child  obtains  more  nutriment  day  by 
day,  but  it  is  by  spontaneously  increasing  the  quantity  according  to 
the  best  rule,  which  is  that  of  normal  appetite,  and  not  by  absorbing 
stronger  and  stronger  food." 

Somewhat  different  conclusions  are  reported  by  Vanderpoel 
Adriance  and  John  S.  Adriance,  based  upon  analyses  of  the  milk  of 
120  healthy  mothers  at  the  Nursery  and  Childs'  Hospital,  New  York. 
In  each  case  the  sample  was  obtained  after  allowing  the  infant  to 
nurse  for  two  minutes,  and  periods  studied  were  from  the  second 
day  to  the  fifteenth  month  of  lactation.  They  found  that  of  all  the 
ingredients  of  human  milk  the  fat  varies  most,  and  varies  throughout 
lactation,  the  extremes  being  7.61  and  1.31  per  cent.  The  fat  bears 
a  rough  general  proportion  to  the  proteid  of  3:1.  The  carbohydrate, 
which  weighs  during  the  middle  period  of  lactation  more  than  all 
the  other  solids  together,  increases  throughout  lactation,  and  ranges 
from  5.35  to  7.95  per  cent. 

The  protein  percentage  is  highest  during  the  colostrum  period, 
when  it  may  reach  8.60  per  cent,  and  falls  rapidly  towards  the  end 
of  lactation.  Pfeiffer  found  it  as  low  as  1.52  at  the  seventh  month, 
but  this  is  extreme  reduction.  It  is  increased  by  worry  and  nervous- 
ness and  by  lack  of  exercise;  it  is  lessened  by  reduction  of  meat  in 
the  dietary,  and  vice  versa.  It  comprises  calcium-casein,  lactalbumin 
and  lactoglobulin.  The  salts  <fiminish  from  .27  per  cent  on  the 
second  day  to  .14  at  the  fifteenth  month. 

The  average  specific  gravity  is  1.032.  It  is  lessened  by  increase  of 
fat  and  increased  by  increase  of  proteid,  varying  from  1.026  to  1.036. 

The  energy  derivable  from  human  milk  averages  650  calories  per 
kilogram  of  milk,  as  compared  with  700  calories  for  cow's  milk. 

Human  colostrum  differs  from  the  later  milk  as  follows:  It  con- 
tains colostrum  corpuscles  which  remain  from  seven  to  ten  days;  it 
has  a  yellow  color,  which  disappears  with  the  corpuscles;  it  is 
laxative  to  the  infant;  its  fat  varies  greatly,  averaging  2  per  cent; 
the  quantity  of  sugar  is  lowest  and  of  protein  and  ash  highest  of 
any  period  of  lactation. 

Drugs  in  Human  Milk. —  Many  drugs  are  excreted  through  the 
mother's  milk,  and  it  is  often  the  case  that  an  infant  is  affected  by 
suckling  such  milk.  It  is  possible  to  act  upon  infants  through  this 
medium,  but  the  strength  of  solution  in  which  the  drug  reaches  them 


62          FOODS  AND  FOOD  PREPARATIONS 

is  far  too  uncertain.  An  infant  has  been  killed  by  suckling  a 
mother  who  had  taken  an  overdose  of  laudanum  (Fletcher).  Acids 
given  to  a  nursing  mother  may  cause  colic  in  the  child.  Neutral 
salts  loosen  the  bowels,  and  potassium  salts  act  as  diuretics  for 
infants  when  taken  by  the  mother.  Aromatic  oils,  and  probably  all 
volatile  oils,  reappear  in  the  mother's  milk.  The  agreeable  taste 
of  some  of  these  substances  causes  the  child  to  suck  harder,  and 
excites  thereby  a  reflex  stimulation  of  the  mammary  glands  to  fur- 
ther secretion. 


FIG.    7A. —  HITMAN    COLOSTRUM 
(Funke). 


FIG.  7B. —  WOMAN'S  MILK  AT  A  LATE 
PERIOD   ( Funke ) . 


Among  other  dmgs  which  have  been  determined  in  the  mother's 
milk  after  ingestion  by  the  stomach^are :  Senna,  rhubarb,  scammony, 
alcohol,  ether,  colchicum,  salicylic  acid,  hemlock,  veratrine,  sulphur, 
castor  oil,  ammonium  salts,  turpentine,  copaiba,  anise,  dill,  garlic, 
wormwood,  and  jalap.  Antimony  passes  readily  into  mother's  milk, 
and  should  not  be  given  to  nursing  women.  Potassium  iodide,  cor- 
rosive sublimate,  and  other  mercurial  salts,  arsenic,  zinc,  and  lead, 
all  may  be  excreted  in  the  milk  at  periods  varying  from  four  hours 
to  several  days  after  their  administration  and  continue  to  be  elimi- 
nated for  a  day  or  two  after  the  drug  has  been  withheld. 

Vegetable  acids  give  rise  to  carbon  dioxide  in  milk.  If  nursing 
mothers  partake  freely  of  fresh  fruit  and  green  vegetables  their  milk 
may  gripe  and  purge  their  infants.  Violent  exercise  and  violent 
mental  emotion  are  harmful  to  the  milk. 

Goat's  mill-  is  the  least  digestible  and  nutritious  of  milks,  although 
it  contains  the  most  solids.  It  is  scarcely  used  at  all  in  the  United 
States  except  sometimes  by  very  poor  foreigners,  as  it  is  in  Switzer- 


ANIMAL  FOODS  63 

land  and  other  mountainous  European  countries,  but  for  some  East- 
ern tribes  it  is  a  staple  variety  of  milk.  Cheese  also  is  made  from  it 
on  a  large  scale.  It  has  a  peculiar  strong  odor  and  taste,  which  are 
disagreeable  to  those  who  are  unaccustomed  to  it,  and  which  are  par- 
tially expelled  by  boiling.  They  are  due  to  a  substance  called  hircin 
or  hircic  acid. 

Goat's  milk  contains  an  excess  of  fat,  and  for  this  reason  is  too 
rich  for  infant  food,  and  gives  rise  to  vomiting  and  diarrhoea.  The 
coagulae  formed  by  it  are  very  tough.  It  is  known  to  afford  a  means 
of  transmission  of  Malta  Fever  by  conveying  the  specific  Micrococcus 
melitensis. 

Ass's  milk  contains  the  least  solids  of  all  the  edible  milks,  except 
mare's  milk,  and  is  poor  in  casein  and  fat.  It  has  a  fair  proportion 
of  sugar,  more  than  cow's  milk  but  less  than  human  milk.  Ass's 
milk  is  sweet  and  easy  of  digestion,  although  it  has  a  tendency  to 
cause  diarrhoea. 

Experiments  in  the  feeding  of  children  direct  from  asses  were 
conducted  in  Paris  in  1883  at  the  Hospice  des  Enfants  Assistes. 
One  ass  sufficed  to  nourish  three  infants  besides  her  own  foal.  The 
asses  were  kept  near  the  ward  and  the  infants  were  brought  to 
them  to  nurse.  Syphilitic  infants  belonging  to  a  class  in  which 
death  had  been  the  invariable  rule  were  thus  nursed,  and  70  per  cent 
were  saved.  The  experiment  does  not  seem  to  have  found  favor  else- 
where. Goats  were  first  tried,  but  proved  of  no  service  for  direct 
nursing. 

Mare's  milk,  like  ass's,  contains  less  protein  and  less  fat,  but  more 
lactose  than  cow's  milk. 

The  casein  of  mare's  milk  is  intermediate  in  digestibility  between 
human  and  cow's  milk.  Both  ass's  and  mare's  milk  are  used  in  the 
steppes  of  Eussia  and  in  .Siberia  for  the  manufacture  of  koumiss. 
(See  Koumiss.) 

Reindeer  milk  contains  18  per  cent  of  solids,  and,  generally  speak- 
ing, those  domestic  animals  living  farthest  north  have  the  most  solids 
in  their  milk. 

Methods  of  Milk  Analysis. —  An  accurate  analysis  of  milk  requires 
much  skill  and  the  equipment  of  a  well-organized  laboratory,  but  it  is 
often  important  for  physicians  to  be  able  to  judge  for  themselves  of 
the  quality  of  food  so  universally  prescribed  by  them,  and  it  is  there- 
fore deemed  appropriate  to  describe  some  of  the  easier  methods  of 
qualitative  examination.  The  minimum  standard  to  which  milk 
must  conform,  as  established  by  the  New  York  City  Health  Board, 
is  as  follows: 


64  FOODS  AND  FOOD  PREPARATIONS 

Per  cent. 

Water 88.00 

Fat 3.50 

Total  solids   12.00 

Solids  not  fat   8.50 

Color,  Taste,  Odor,  Reaction. —  The  normal  color  of  milk  is  white 
and  is  due  to  fat  globules,  but  it  may  be  slightly  yellow,  especially 
if  the  cow  has  been  feeding  in  wheat  fields  (Hind).  The  taste  is 
sweet  and  the  odor  faint  and  fresh.  Poor  milk  often  has  a  bad  odor, 
either  sour  or  derived  from  absorption  from  some  neighboring  ma- 
terial. It  is  sour  to  the  taste,  acid  in  reaction,  and  if  held  to  the 
light  in  a  test  tube  or  small  thin  glass  it  may  have  a  bluish  or 
reddish  tinge  and  appear  watery.  It  curdles  in  tough,  stringy,  or 
glutinous  yellowish  lumps  of  large  size. 

Acid  Test. —  Acid  forms  in  milk  when  first  obtained  from  the  cow. 
Litmus  paper  is  no  longer  regarded  as  a  reliable  test  for  the  acidity 
of  milk,  for  it  reacts  blue  to  many  weak  acids,  and  a  better  test 
has  been  devised  by  Prof.  E.  H.  Farrington.  It  is  described  as 
follows  by  R.  A.  Pearson: 

"  Tablets  containing  a  definite  quantity  of  alkaline  material  (such 
as  caustic  potash  or  soda)  are  dissolved  in  water  and  added  to  a 
measured  amount  of  the  milk  to  be  tested.  The  tablets  contain 
a  little  phenophthalein,  which  is  colorless  when  in  acid  solution  and 
pink  when  in  alkaline  solution.  A  solution  of  these  tablets  is  slowly 
added  to  the  milk  and  the  mixture  is  stirred  until  it  becomes  pink. 
It  is  then  known  that  enough  alkali  has  been  added  to  neutralize 
the  acid  in  the  measured  amount  of  milk  and  the  amount  of  solu- 
tion required  indicates  the  acidity  of  the  milk." 

Litmus  can  displace  portions  of  the  acid  in  milk  and  react  alkaline, 
but  phenophthalein  is  too  weak  to  do  this,  and  hence  furnishes  a 
more  reliable  test. 

It  thus  has  been  shown  that  both  fresh  breast  milk  and  cow's  milk 
are  normally  faintly  acid.  Moreover  C.  G.  Kerley  declares  that : 

"  It  is  generally  recommended  that  5  per  cent,  10  per  cent,  and 
sometimes  25  per  cent  of  lime  water  be  added  to  the  infant's  food, 
or  1  to  2  grains  of  bicarbonate  of  sodium  to  each  ounce  of  food.  In 
antacids  there  is  here  a  great  disproportion,  as  a  20-ounce  mixture 
containing  10  per  cent  lime  water  would  contain  about  iy±  grains 
calcium  hydrate  or  40  grains  bicarbonate  of  sodium.  A  small  quan- 
tity of  filtered  sour  milk  which  contains  lactic  acid,  or  a  stronger 
acid  added  to  feedings  containing  bicarbonate  of  soda,  caused  an 
effervescence,  which  shows  that  the  soda  had  not  acted  as  an  antacid, 
but  remained  unchanged  in  the  feeding. 


ANIMAL  FOODS 


65 


"Hence  the  teaching  that  lime  water,  bicarbonate  of  sodium,  or 
carbonate  of  potassium  should  be  added  to  fresh  milk  or  feedings 
simply  because  they  are  antacids  is  erroneous." 

Estimation  of  Total  Solids. —  To  estimate  the  total 
solids  of  milk  several  tests  are  employed  to  furnish 
data  in  regard  to  the  nutrient  power  of  the  milk  and  to 
detect  adulteration. 

A  common  method  used  by  health  boards  is  to  weigh 
and  evaporate  5  c.c.  of  milk  to  dryness  in  a  small,  flat- 
bottomed,  platinum  crucible  of  a  known  weight.  This 
process  takes  about  an  hour.  The  residue  is  then  dried 
for  an  hour  more  at  100°  F.  and  weighed.  The  milk 
dries  in  two  layers.  The  upper  layer  consists  of  a 
thin  film  of  fat,  which  is  dissolved  in  petroleum  and 
benzine.  The  lower  honeycombed  layer  is  then  washed, 
dried  and  weighed  again.  The  loss  in  weight  after 
removing  the  upper  layer  represents  the  amount  of 
fat  present.  The  soluble  salts  and  soluble  proteid  are 
then  dissolved  out  by  warm  water  and  alcohol  and 
separated.  Ignition  over  a  Bunsen  burner  drives  off 
all  organic  matter,  and  leaves  the  ash,  which  is  again 
weighed. 

Another  less  laborious  method  consists  in  the  use 
of  an  instrument  called  a  "  lactometer,"  by  which  the 
specific  gravity  of  the  milk  is  taken. 

A  lactometer  is  a  glass  spindle  (Fig.  8)  resembling  a 
urinometer,  but  is  about  fifteen  centimeters  long,  and 
floats  in  a  quart  measure.  It  is  graduated  to  measure 
the  specific  gravity  from  0°  (the  water  line)  to  40°. 
Milk  in  which  it  floats  at  below  29°  is  almost  surely 
watered,  or  if  it  floats  above  33°  the  milk  is  skimmed. 
The  specific  gravity  of  the  milk  being  taken  with  the 
lactometer,  the  amount  of  dilution  is  readily  computed 
by  comparing  it  with  the  normal  standard,  30°. 
Suppose  this  specific  gravity  to  be  21°  in  a  given  case, 
then  30 :21 :  :100  :x(=70) .  That  is,  the  normal  grav- 
ity, 30,  is  to  the  gravity  of  the  sample  examined  21,  as 
100  parts  of  normal  milk  are  to  the  sample,  or,  in 
other  words,  only  70  parts  per  hundred  of  the  sample 
are  milk,  and  30  parts  of  water  have  been  added.  To 
facilitate  the  calculation,  the  space  between  0°  and  40°  JTIG.  8.—  LACTO- 
may  be  divided  into  100  parts;  each  division  of  the 


66 


FOODS  AND  FOOD  PREPARATIONS 


second  scale  represents  1°  or  1  per  cent  of  milk.  Thus,  if  the  lacto- 
meter stands  at  50°  of  this  second  scale,  there  is  only  50  per  cent 
of  milk  in  the  sample.  Quevenne's  lactometer  is  graduated  so  that 
each  degree  of  the  scale  corresponds  with  one  degree  of  specific  grav- 
ity of  milk  at  60°  F. 

There  has  been  much  dispute  regarding  the  use  of  the  lactometer, 
on  the  ground  that  an  excessive  amount  of  cream,  on  account  of 
the  lightness  of  the  fat,  diminishes  the  specific  gravity  of  a  really 
rich  milk.  On  the  other  hand,  it  is  claimed  that  the  diminished 
gravity  is  always  due  to  increase  in  the  quantity  of  water,  and  that 
milk  rich  in  cream  will  also  contain  less  water,  and  therefore  main- 
tain the  normal  standard.  The  matter  has  been  tested  in  the  courts, 
and  in  New  York  city  the  lactometer  test  alone  is  always  sufficient 
to  insure  conviction  in  trials  for  adulteration  of  milk  with  water. 

Sometimes  in  estimating  the  specific  gravity  acetic  acid  is  first 
added  to  precipitate  the  casein,  which  is  removed  with  the  fat;  the 
specific  gravity  of  the  whey  is  then  taken.  Hassell  claims  that  the 
latter  is  more  constant  than  the  specific  gravity  of  milk  itself. 

L.  Emmet  Holt  furnishes  the  following  table  of  variations  in 
specific  gravity  of  human  milk  and  their  causes,  as  determined  by  a 
lactometer  of  his  own  device  (Fig.  9,  p.  67)  : 

Human  Milk    (Holt). 


Specific  gravity 
70    F. 

Cream—  24  hours. 

Proteids. 

Normal    average   . 

1.031     

8  per  cent  

1.5   per   cent. 

Healthy  variations 
Healthy  A7ariations 

1.028  to   1.029. 
1.032  to   1.033. 

9  to  12  per  cent.   .  .  . 
5  to  6  per  cent  

Normal  (rich  milk). 
Normal   (fair  milk). 

Unhealthy     varia- 
tions      

Below  1.028    .  . 

High    (above    10    per 

cent)      

Normal    or    slightly 

Variations         .... 

Below   1  028 

Normal    (5  to  10  per 

.below. 

cent  )  

Low. 

Variations         .... 

Below   1  028 

Low      (below     5     per 

cent  )  

Very  lo\v  (very  poor 

4bove   1  033 

High    

milk). 
Very  high  (  very  rich 

Variations     

Above   1.033    .  . 

milk). 
High. 

Variations     

Above   1.033    .  . 

Low 

Normal     (or    nearly 

so). 

Estimation  of  the  Cream  and  Fat. —  To  estimate  the  quantity  of 
cream  the  sample  of  milk  is  allowed  to  stand  in  a  cool  place  for 
twenty-four  hours  in  a  "  creamometer."  This  is  a  simple  glass  tube 
twenty-five  millimeters  wide  and  twenty-five  centimeters  deep,  which 


ANIMAL  FOODS 


67 


is  graduated  in  hundredths  from 
above  downward.  It  is  filled  with 
milk  to  the  zero  level.  The  cream 
rises  to  the  top,  and  the  percentage 
of  volume  is  read  off. 

This  method  is  amplified  by 
Marchland's  process,  in  which  a 
similar  graduated  tube  is  employed, 
but  the  fat  is  more  completely 
separated  by  means  of  the  addition 
of  ether  and  a  little  liquor  sodas. 
Ninety-five  per  cent  alcohol  is  then 
put  into  a  flask  with  the  milk,  and 
the  whole  is  vigorously  shaken,  af- 
ter which  it  is  allowed  to  stand  at 


— — 0 


-30 


—  50 


1 

010 

- 

1, 

020 

1, 

030 

1 

010 

\ 

I 

^ 

-'  . 

1~: 

FIG.  10. —  CREAMOMETER. 

(R.    A.    Pearson,    Farmers' 

Bui.,  No.  42.) 


A  B 

FIG.  9. —  HOLT'S  APPARATUS  FOR  EX- 
AMINATION OF  WOMAN'S  MILK.  A, 
Lactometer;  B,  Cream-gage. 

130°  to  140°  F.  In  half  an  hour  the  fat 
forms  a  distinct  layer  at  the  top  of  the 
graduated  tube.  The  error  by  this  process 
is  said  to  be  less  than  0.3  per  cent. 

The  richness  of  the  milk  in  cream,  or  its 
dilution  with  water,  also  may  be  measured 
by  its  opacity.  5  c.c.  of  water  are  placed  in 
a  glass  cell,  called  a  "  lactoscope "  or 
"  diaphanometer "  (Dome),  with  parallel 
sides,  through  which  a  candle  placed  at  a 
distance  of  a  meter  may  be  seen.  More 
milk  is  then  added,  drop  by  drop,  until  the 
opacity  of  the  cell  contents  obscures  the 
light.  This  method  is  more  tedious  and 
less  accurate  than  the  previous  one.  Cream 
varies  in  specific  gravity  between  1.010  and 
1.024. 


68 


FOODS  AND  FOOD  PREPARATIONS 


A  simple  method  of  roughly  determining  the  quantity  of  fat  in 
human  milk  is  given  by  Nias.  The  milk  is  placed  in  a  test  tube, 
made  distinctly  alkaline  by  a  few  drops  of  liquor  potassae,  boiled, 
and  left  for  a  few  hours  in  a  warm  place.  The  fat,  floating  on  the 
surface,  is  then  estimated  by  graduations  on  the  side  of  the  test  tube. 
It  is  of  course  necessary  to  use  test  tubes  of  uniform  caliber  in  making 
comparative  tests. 

In  order  to  determine  fat  percentage  in  milk  or  cream  with  ac- 
curacy, less  crude  methods  must  be  used.  Concentrated  mineral  acids 
liberate  the  oil  globules  held  in  suspension  as  natural  emulsion  in 
milk  fat,  thereby  enabling  them  to  float  promptly  and 
completely  to  the  surface.  The  use  of  a  centrifugal  ma- 
chine accelerates  this  separation.  Adopting  these  princi- 
ples S.  M.  Babcock  devised  a  cream  test- 
ing apparatus  which  is  illustrated  by  Figs. 
12  and  13  (p.  69).  (It  is  similar  to  a 
Swedish  apparatus  used  by  the  New  York 
Board  of  Health.)  Directions  for  its  use 
are  briefly  summarized  as  follows :  A  few 
ounces  of  milk  are  agitated  first  in  a 
carafe  to  secure  a  uniform  mixture  of  the 
cream  in  the  milk.  A  pipette  holding 
17.6  c.c.  (Fig.  12,  e)  is  filled  with  the 
milk  which  is  transferred  to  a  small  test 
bottle  (capacity  .50  c.c.,  Fig.  12  i)  having 
a  slender  graduated  neck.  A  glass  cylin- 
der (Fig.  12,  g)  holding  17.5  c.c.  is  filled 
with  sulphuric  acid  (Fig.  12,  c)  which  is 
slowly  added  to  the  milk  in  the  test  bottle 
(Fig.  12,  i),  and  carefully  mixed  by  rotat- 
ing the  bottle  by  hand.  The  test  bottle  is 
then  placed  in  the  centrifuge  (Fig.  13,  A) 
and  rotated  five  minutes  at  a  speed  of  about  1,000  revolutions  per  min- 
ute. Hot  water  is  next  added  to  dilute  the  sample  further,  until  the 
fat  floats  into  the  neck  of  the  bottle.  By  again  centrifuging  the 
bottle  once  or  twice  and  again  adding  a  few  drops  of  water, 
the  lower  part  of  the  column  of  fat  in  the  neck  is  brought  to  rest 
at  a  level  with  the  bottom  of  a  scale  (graduated  in  percentage) 
marked  upon  the  neck  of  the  bottle.  The  height  of  the  column  of 
fat  thus  may  be  read  by  means  of  the  scale.  To  facilitate  the  read- 
ing, the  points  of  a  pair  of  dividers  (Fig.  13,  D)  are  held  respectively 
at  the  upper  and  lower  surface  of  the  layer  of  fat.  The  centrifuge 


A 


B 


FIG.  11. —  TUBES  USED  FOR 
DETERMINING  THE  FAT  IN 
MILK.  A,  Babcock's  tube 
for  cow's  milk ;  B,  Lewis's 
modification  for  woman's 
milk  (Holt). 


ANIMAL  FOODS 


69 


is  adapted  to  hold  from  eight  to  thirty  test  bottles  so  that  the  milk 
of  as  many  cows  may  be  tested  simultaneously.  The  Babcock  test 
has  proved  sufficiently  accurate  for  all  practical  purposes,  and  it 
admits  of  estimations  to  within  one-tenth  of  one  per  cent.  It  may 


a        b  c  defghijk  I 

FIG.    12. —  THE    BABCOCK   CREAM-TESTING   APPARATUS. 

a,  6,  Bottles  for  mixing  Milk  and  Acid;  c,  Sulphuric- Acid  Bottle;  d,  Grad- 
uator;  e,  f,  Z,  Pipettes  for  measuring  Milk;  g,  k,  Cylinders  for  measur- 
ing acid;  h,  i,  j,  Test  Bottles  for  use  in  Centrifuge. 


A 


B 


FIG.    13. —  THE    BABCOCK    CREAM-TESTING    APPARATUS. 

A,  Centrifuge  for  holding  8  Flasks  (the  necks  of  two  flasks  are  seen  in  situ; 
B,  One  of  the  flasks;  C,  Lid  and  crank  of  the  Centrifuge;  D,  Callipers 
for  measuring  the  scale  on  the  neck  of  the  flask;  E,  Scales  showing  flask 
in  situ. 

be  employed  to  determine  the  fat  content  of  human  as  well  as 
cow's  milk.  As  the  test  bottles,  made  in  large  quantities,  show  slight 
variations  in  the  diameter  of  their  necks,  the  neck  of  each  bottle 
may  be  measured  or  "  calibrated  "  by  inserting  a  standardized  plug 


70  FOODS  AND  FOOD  PREPARATIONS 

of  metal  or  glass  and  comparing  the  scale  on  the  neck  of  the  bottle 
with  the  accuracy  with  which  the  plug  fits  the  neck.  (Fig.  12,  h 
shows  the  calibrator  inserted  in  the  neck  of  a  test  bottle.) 

When  cream  instead  of  milk  is  to  be  tested  for  its  fat  content, 
it  is  diluted  first  with  an  approximately  equal  volume  of  water  and 
poured  into  several  test  bottles,  the  readings  from  all  of  which 
when  added  together,  give  the  correct  percentage  of  fat.  Samples 
of  cream  are  also  weighed  upon  a  small  scales  adapted  to  hold  the 
test  bottles  (Fig.  13,  E).  The  percentage  reading  of  the  column  of 
fat  in  the  test  bottle  is  multiplied  by  18  and  the  product  divided 
by  the  ascertained  weight  of  the  cream,  which  gives  the  corrected 
fat  percentage  in  the  cream. 

Estimation  of  Lactose. —  The  method  of  quantitative  estimation  of 
milk  sugar  is  the  same  as  that  employed  for  glucose  in  the  urine. 
The  casein  is  first  precipitated  by  acetic  acid.  The  whey  is  filtered 
and  tested  with  Fehling's  copper  solution  or  with  a  polariscope.  Con- 
venient tables  are  made  to  facilitate  the  calculation. 

Estimation  of  Albuminoids. —  In  the  method  of  Nias  to  determine 
the  albuminoids  the  sample  of  milk  is  placed  in  a  graduated  test 
tube,  as  if  to  estimate  the  cream,  and  after  some  hours  the  super- 
natant fat  is  drawn  off  by  a  pipette.  Acetic  acid  next  is  added  until 
a  strongly  acid  reaction  develops.  The  milk  is  then  boiled.  All 
the  albuminoids  are  precipitated,  and  after  standing  overnight  the 
quantity  may  be  read  off  on  the  side  of  the  graduated  tube. 

Milk  Adulteration  and  Impurities. —  The  prevention  of  adulteration 
and  contamination  of  milk  is  a  matter  of  vital  importance  from 
both  an  economic  and  hygienic  standpoint.  Children,  who  are  so 
largely  dependent  upon  milk,  do  not  well  tolerate  its  adulteration, 
and  milk  is  so  much  used  as  a  raw  food  —  perhaps  more  than  any 
other  one  article  of  diet  —  that  its  careful  inspection  in  regard  to 
contamination  by  disease  germs  or  adulterants  is  imperative,  and 
the  constant  vigilance  of  the  health  boards  of  large  cities  is  required 
to  protect  the  public  from  imposition.  According  to  H.  D.  Chapin 
and  G.  B.  Fowler,  of  the  Milk  Commission  appointed  by  the  Medical 
Society  of  the  County  of  New  York  to  investigate  the  milk  supply 
of  that  city  in  1900,  "over  6,000  children  under  five  years  died  in 
New  York  city  during  the  year,  from  diarrhceal  diseases  largely 
due  to  drinking  old  and  contaminated  milk."  With  more  intelligent 
methods  this  mortality  recently  has  been  much  reduced. 

It  is  better  and  simpler,  however,  for  much  of  the  inspection  to 
be  done  at  the  dairy  farms,  and  in  many  parts  of  this  country  the 
State  Boards  of  Health  appreciate  the  importance  of  this  matter,  and 


ANIMAL  FOODS  71 

the  sale  of  milk  from  diseased  cows  is  prevented  at  first  hand.  When 
a  cream  separator  at  a  dirty  creamery  is  cleaned  it  is  often  found 
to  contain  a  residue  of  manure,  hairs,  dirt,  and  perhaps  pus  and 
blood  from  .inflamed  udders. 

The  examination  of  milk  implies  the  adoption  of  a  legal  standard 
of  quality.  In  New  York  city  the  Health  Board  depends  chiefly 
upon  the  use  of  the  lactometer  above  described.  (See  Estimation  of 
Total  Solids,  page  65).  In  States  such  as  Massachusetts,  Ehode 
Island,  and  Maine  a  chemical  analysis  is  required  by  law.  The 
normal  specific  gravity  established  is  1.030  (in  New  York  1.029), 
and  the  normal  average  amount  of  cream  is  8  per  cent  by  volume. 

The  inspection  of  milk  in  large  cities  and  towns  is  made  at 
the  railway  stations  or  ferries  where  the  cans  are  received.  The 
examination  is  under  the  direction  of  expert  officers,  usually  mem- 
bers of  the  local  Health  Board.  It  is  impossible  and  unnecessary  to 
examine  all  the  milk  brought  in,  but  the  officers  make  frequent 
seizures  and  destroy  at  once  all  milk  found  below  the  legal  standard. 
Milk  sold  in  shops  and  otherwise,  also  should  be  examined  occasionally, 
for  its  dilution  and  adulteration  is  very  easy  and  profitable  to  the 
unscrupulous.  Gross  impurities  in  milk,  such  as  dirt,  hair,  etc., 
may  be  removed  by  filtration  through  absorbent  cotton.  A  few 
germs  are  also  removed  in  this  manner.  A  noted  milk  dealer  of 
Berlin,  who  dispenses  60,000  quarts  of  milk  daily,  forces  it  through 
gravel  filters  from  below  upward,  thereby  removing  the  gross  im- 
purities. 

MILK  MAT  BE  ALTERED  BY 

1.  Addition  of  water,  pure  or  impure.  2.  Addition  of  coloring  mat- 
ter. 3.  Addition  of  preservatives.  4.  Addition  of  substances  used 
for  thickening  after  dilution. 

1.  Dilution  with  Water.—  The  commonest  method  of  adulterating 
milk,  and  the  one  often  most  difficult  of  detection,  is  by  dilution 
with  water.     If  the  water  thus  used  is  pure  it  does  no  harm  other 
than  to  defraud  the  consumer;  but  if  impure,  as  it  often  is  when 
drawn   from   wells   near   manure   heaps,   in  barnyards,   or   country 
privies,  it  may  prove  fatal. 

2.  Coloring  Matter. —  The  normal  whiteness  and  opacity  of  milk 
is  due  to  its  fat  globules.     If  milk  has  been  much  diluted  it  becomes 
pale  and  bluish,  and  both  milk  and  cream  are  sometimes  artificially 
colored  with   anilines   or  other  pigments.     This  form  of   fraud   is 
less  injurious  to  health  than  the  others,  for  only  very  minute  quan- 
tities of  coloring  matters  are  employed.     Annotto  is  the  commonest 
dye  used  to  impart  a  yellow  color  to  milk,  cream,  and  butter.     It  is 


72  FOODS  AND  FOOD  PREPARATIONS 

prepared  from  the  seeds  of  a  tropical  American  tree  (Bixa  orellana). 
It  is  detected  by  allowing  the  milk  to  stand  in  a  tall  glass,  when 
the  lower  stratum  will  contain  the  pigment  associated  with  the  casein 
instead  of  remaining  colorless,  while  the  naturally  yellower  cream 
floats  on  top.  The  cow's  food  may  sometimes  color  the  milk  red  or 
pink,  and  it  may  be  so  stained  by  traces  of  blood,  in  which  latter 
case  the  lower  layers  are  of  deeper  hue  than  the  upper. 

3.  Preservatives. —  Various  substances  are  added  to  milk  and  its 
products  —  condensed  milk,  butter,  cheese,  and  koumiss  —  to  prevent 
souring.     These  are  usually  bicarbonate  or  benzoate,  borax,  or  boric 
acid.     Salicylic  acid  and  formaldehyde  are  less  used.     In  small  quan- 
tities they  do  not  affect  its  taste  or  hurt  the  digestion  of  adults,  but 
they  may  be  injurious  and  even  fatal  to  infants,  and  their  use  should 
be  discountenanced.     The  presence  of  boric  acid  is  detected  by  mixing 
one  part  of  milk  with  two  parts   each   of   hydrochloric   acid   and 
saturated   turmeric  tincture.     After   drying   on   a  water  bath   and 
adding  a  little  ammonia,  a  dark-blue  color  appears  which  changes 
to  green.     (See  Food  Preservatives.) 

4.  Thickening. —  Both  milk  and  cream,  after  dilution  with  water, 
are  sometimes  thickened  again  with  such  substances  as  flour,  arrow- 
root, farina,  whiting,  chalk,  tragacanth,  or  carbonate  of  magnesia, 
which  disguise  the  natural  blueness  of  the  attenuated  fluid.     Effer- 
vescence in  milk  produced  by   addition  of  a   strong  mineral   acid 
shows  the  presence  of  carbonates.     Sugar  is  added  to  raise  the  specific 
gravity  of  diluted  skimmed  milk. 

MILK  IS  CONTAMINATED  OR  RENDERED  UNFIT  FOR  USE  BY 

1.  Improper  or  poisonous  foods  eaten  by  the  animal.  2.  Poor  con- 
dition of  the  animal,  due  to  nursing,  worrying,  etc.  3.  Contamina- 
tion by  disease  germs  from  the  cow.  4.  Contamination  by  extraneous 
disease  germs.  5.  Souring  and  decomposition.  6.  Absorption  of  bad 
odors. 

1.  Poisonous  Foods. —  The  color  of  milk  is  affected  by  various  sub- 
stances ingested  by  the  cow;  thus  madder  turns  it  saffron,  rhubarb 
makes  it  red  or  yellow,  and  it  is  colored  blue  by  certain  drugs.  The 
color  is  then  uniform  throughout  the  milk,  and  not  superficial  as  in 
the  case  of  the  blue  imparted  by  the  growth  of  fungi,  as  described 
on  page  76.  If  milk  be  made  blue  by  addition  of  litmus  solution  it 
may  be  reddened  by  action  of  such  germs  as  the  lactic-acid  bacillus, 
the  Bacillus  typliosus,  and  the  Streptococcus  pyogenes. 

Cows  fed  on  brewers'  swill  or  refuse  of  glucose  factories,  or  cows 
allowed  to  eat  decaying  autumn  leaves,  garlic,  certain  injurious 
meadow  plant?,  or  strong-smelling  plants  like  cabbages,  turnips, 


ANIMAL  FOODS  73 

and  wild  onions,  will  yield  unhealthy,  strong-smelling,  bad-tasting,  or 
deteriorated  milk.  This  so-called  "bitter  milk"  may  be  so  rendered 
by  a  yeast  fungus,  the  Torula  amara,  found  on  the  leaves  of  trees. 
The  bitter  taste  may  be  imparted  to  cheese  and  butter. 

Beets  tend  to  make  cow's  milk  acid.  Cows  should  not  be  given 
unclean  water  to  drink.  Offensive  odors  and  tastes  imparted  to  milk 
through  the  cow,  or  by  absorption  from  surrounding  substances,  are 
most  intense  while  the  milk  is  fresh ;  whereas  if  due  to  bacteriological 
influences,  they  become  apparent  only  after  some  hours,  and  go  on 
increasing.  H.  Weller  found  nearly  1  per  cent  of  alcohol  in  milk 
from  cows  fed  on  distillery  slops  which  contained  6  per  cent  of  it. 

2.  Unhealthy  Cows. —  The  milk  first  secreted  after  calving    (co- 
lostrum)  contains  more  albumin  than  casein.     It  is  viscid,  turbid, 
frothy,  yellow,  slightly  acid,  and  coagulates  on  boiling.     In  the  cow 
colostrum  has  a  sickly  odor,  and  is  purgative  even  when  cooked.     It 
remains  so  for  about  a  month  after  parturition.     Colostrum  corpuscles 
may  be  easily  detected  by  microscopic  examination. 

The  bulling  cow  may  be  highly  nervous  during  ovulation,  and,  as 
a  reflex  consequence,  her  milk  becomes  acid.  Cows  which  are  teased 
and  worried  by  dogs  or  otherwise,  or  made  to  exercise  too  much, 
give  milk  which  sours  easily  and  disagrees  with  infants.  Underfeed- 
ing makes  the  animal  give  inferior,  watery  milk. 

3.  Disease  Germs. —  Cows  suffering  from  certain  diseases  may  trans- 
mit them  through  their  milk  to  man,  although  this  method  of  in- 
fection is  less  common  than  that  through  milk  to  which  germs  have 
had  access  in  process  of  handling  or  transportation.     The  principal 
disease  which  may  be  derived  from  the  cow  through  her  milk  is 
tuberculosis.     George  M.  Kober  of  Washington  states  that : 

"  The  milk  of  animals  suffering  from  acute  specific  enteritis, 
puerperal  and  other  septic  fevers,  foot-and-mouth  disease,  cowpox, 
anthrax,  pleuropneumonia,  rabies  and  tetanus  has  also  been  known 
to  produce  sickness  in  the  consumer." 

The  Massachusetts  Society  for  Promoting  Agriculture,  in  a  re- 
port upon  "  The  Infectiousness  of  Milk,"  confirms  the  fact  that  milk 
from  cows  having  tubercular  udders  is  infectious  to  man.  The 
question  of  tuberculosis  transmission  through  milk  is  fully  discussed 
on  page  432.  Tuberculous  milk  is  of  poorer  quality,  thinner,  and 
bluer  than  normal  milk. 

Cases  have  been  reported  of  infection  of  a  nursing  infant  through 

a  tuberculous  mother's  milk,  and  calves  are  undoubtedly  so  infeected 

through  cows;  but  it  should  be  remembered  that  the  infant  is  much 

exposed  to  infection  by  its  mother's  sputum,  and  may  inhale  dried 

8 


74          FOODS  AND  FOOD  PREPARATIONS 

sputum  from  beneath  her  bedclothing  or  within  the  room.  However, 
the  presence  of  tubercle  bacilli  has  been  demonstrated  indubitably  at 
least  a  half  dozen  times  in  human  breast  milk. 

The  foot-and-mouth  disease  of  cattle  is  transmitted  to  man  if  the 
milk  of  cows  so  affected  be  drunk  without  boiling,  which  destroys 
the  germs  (Bollinger).  This  disease  is  transmitted  (from  sores  upon 
the  udders  or  nipples)  even  when  the  milk  is  diluted  ten  times 
or  taken  in  coffee  or  tea,  but  adults  must  drink  a  good  deal  of  it 
in  order  to  become  affected.  Butter  and  cheese  made  from  such  milk 
also  convey  the  infection  (Schneider).  The  foot-and-mouth  disease 
diminishes  the  quantity  of  milk  given  by  the  cow  by  one-half,  and 
the  milk  coagulates  too  quickly  and  has  a  yellowish  colostrum-like 
appearance.  If  the  disease  be  severe  the  milk  separates  into  slimy 
coagulas  and  whey,  and,  on  boiling,  curdles  in  stringy  masses.  In 
other  cases  the  taste  is  acid,  and  on  standing  twelve  hours  a  yellow 
sediment  is  precipitated  having  a  nauseous,  rancid  odor. 

4.  Extraneous  disease  germs  may  find  their  way  into  milk  through 
contact  with  unclean  hands,  or  from  polluted  water  used  for  dilution, 
or  for  washing  cans  and  pans. 

Soxhlet  says  that  if  mother's  milk  were  fed  like  cow's  milk  after 
as  much  careless  handling,  it  would  produce  as  much  disease.  Calves 
have  been  known  to  acquire  diarrhoea  when  fed  milk  from  unclean 
pails,  and  the  animals  were  cured  by  allowing  them  to  suck  the 
very  cows  that  had  been  milked  into  the  pails. 

Cow's  milk  is  too  often  tainted  with  excrementitious  matter  from 
the  stable  or  cow  yard.  The  cows  lie  upon  foul  bedding,  or  be- 
spatter their  udders  continually  in  barnyard  filth.  Soxhlet  has  said 
that  in  judging  the  quality  of  milk  one  should  consider  "  not  so  much 
what  the  cow  fed  on,  as  rather  what  kind  of  cow  dung  the  milk 
contains." 

The  following  data  from  the  report  of  a  commission  of  disin- 
terested physicians  upon  the  "  Walker-Gordon  guaranteed  milk  "  from 
the  dairy  at  Plainsboro,  N.  J.,  exhibit  an  ideal  system  of  cleanli- 
ness :  Each  milkman  before  milking  is  required  to  cleanse  his  hands 
in  hot  water  with  soap  and  a  nail-brush ;  he  then  dons  a  clean  white 
linen  suit  from  the  sterilizing  chamber,  and  takes  a  clean  towel  and 
milking-stool ;  he  is  not  allowed  to  moisten  his  hands  with  the  milk 
in  milking,  and  he  must  wash  his  hands  each  time  before  milking 
another  cow.  All  cows  must  have  given  a  negative  tuberculin  test, 
and  all  are  groomed  twice  a  day  before  milking.  Pine  shavings  are 
used  for  bedding.  The  milk  is  drawn  into  pails  with  small  openings, 
to  exclude  droppings  from  the  animal's  belly.  The  milk  is  strained 


ANIMAL  FOODS  75 

through  sterilized  absorbent  cotton  and  placed  in  a  cooler,  which 
reduces  the  temperature  to  40°  F.  within  twenty  minutes  after  leav- 
ing the  udder.  It  is  then  bottled  and  stored  in  ice  water  ready  for 
shipment. 

•William  H.  Park  and  L.  Emmet  Holt  analyzed  the  milk  bought 
in  stores  in  the  tenement  districts  in  New  York  city,  and  its  effect 
upon  infant  feeding.  Some  of  their  conclusions  follow:  In  winter 
the  average  number  of  non-specific  bacteria  present  in  store  milk  is 
750,000  per  c.c.,  a  number  which  does  not  appear  to  be  harmful.  In 
summer  over  1,000,000  bacteria  per  c.c.  of  milk  are  always  harmful 
to  young  infants,  and  the  number  may  reach  several  hundred  mil- 
lions per  c.c.  More  than  139  varieties  of  bacteria  were  represented 
in  the  various  samples  of  milk,  no  one  of  which  appeared  to  be 
especially  related  to  the  summer  diarrhoeas  of  infancy.  After  the 
first  year  of  life  the  bacteria  of  milk  seemed  to  produce  very  little 
disturbance  in  children  unless  present  in  enormous  excess.  First 
class  bottled  milk  from  high  grade  dairies  seldom  contains  less  than 
10,000  bacteria  per  c.c.,  and  frequently  has  100,000. 

Milk  carelessly  transported  promptly  absorbs  germs  from  the  air 
or  from  unclean  receptacles,  and  it  is  an  excellent  culture  medium 
for  rapid  growth  of  such  germs  as  those  of  tuberculosis,  scarlatina, 
and  diphtheria,  which  may  gain  access  to  it  in  that  manner.  Milk, 
however,  possesses  mild  germicidal  and  agglutinating  power  against 
certain  microorganisms,  including  the  Bacillus  typhosus.  When  local 
epidemics  of  such  diseases  break  out,  there  always  should  be  a  thor- 
ough investigation  of  the  sources  of  milk  supply,  and  a  bacteriological 
examination  of  the  milk  should  be  instituted.  Many  persons  imagine 
that  a  chemical  analysis  is  sufficient,  but  this  is  useless  for  detection 
of  disease  germs. 

George  M.  Kober  collected  data  of  330  outbreaks  of  infectious  dis- 
eases of  various  kinds  due  to  milk  infection,  and  which  had  been 
recorded  prior  to  1901,  195  of  which  were  of  typhoid  fever,  74  of 
scarlatina  and  28  of  diphtheria.  Such  epidemics  are  more  common 
in  England  than  in  America,  and  least  often  appear  in  continental 
Europe,  owing  to  the  comparative  infrequency  with  which  raw  milk 
is  drunk  there  by  both  infants  and  adults. 

Severe  epidemics  of  typhoid  fever  have  of  late  years  been  attributed 
to  infected  milk  by  H.  E.  Smith,  at  Waterbury,  Conn.;  by  L.  H. 
Taylor,  at  Wilkesbarre,  Pa. ;  and  by  Littlejohn,  who  traced  the  origin 
of  sixty-three  cases  to  one  dairy.  Fourteen  cases  of  typhoid  fever 
occurring  in  East  Barrington,  1ST.  H.,  in  1896,  were  traced  to  the 
eating  of  ice-cream  contaminated  by  a  milkman  who  had  continued 


76          FOODS  AND  FOOD  PREPARATIONS 

milking  while  himself  suffering  from  the  fever.  No  one  who  is 
nursing  a  case  of  typhoid  or  scarlet  fever  or  diphtheria,  or  who  in 
any  way  handles  the  discharges  or  clothing  of  such  patients,  should 
be  allowed  to  touch  milk  or  milk  receptacles,  much  less  to  milk 
a  cow. 

Typhoid  bacilli  also  have  been  proved  capable  of  living  in  butter. 

At  Brewster,  New  York,  Miller  reported  twenty-four  cases  of  scar- 
•latina  which  occurred  among  those  who  drank  the  milk  supplied  by  one 
dairyman  while  his  daughter  had  scarlet  fever.  The  disease  was 
not  otherwise  prevalent  in  the  town  at  the  time. 

E.  Hart  reported  at  the  Seventh  International  Medical  Congress 
a  series  of  epidemics  in  England  the  origin  of  which  he  had  traced 
to  milk.  Of  these,  fifty  were  of  typhoid  fever,  fourteen  of  scarlatina, 
and  seven  of  diphtheria. 

The  diphtheria  bacillus  thus  far  has  not  been  proved  to  be  trans- 
mitted direct  from  the  cow  to  man,  but  cows  inoculated  under  the 
shoulder  with  diphtheritic  microbes  exhibit  the  germs  in  the  milk 
after  developing  local  lesions  of  the  udders.  Those  epidemics  of 
diphtheria  the  spread  of  which  has  been  attributed  to  milk  have 
probably  been  due  to  contamination  through  the  handling  of  the 
milk  by  milkers  or  dairymen  having  the  disease  themselves  or  who 
have  been  in  close  contact  with  it.  In  this  country  Goodwin  and 
W.  H.  Stillwin  have  both  reported  such  epidemics  occurring  in 
Michigan  in  1879.  W.  J.  Howard,  Jr.,  studied  an  epidemic  of  100 
cases  in  49  houses  in  Ashtabula,  Ohio,  in  1894,  which  he  is  confi- 
dent was  referable  to  a  milk  supply  delivered  by  boys  who  had 
severe  angina  at  the  time,  although  the  Bacillus  diphtheria  was  not 
found  in  their  throats.  The  New  York  Health  Board  reported  the 
discovery  of  the  germs  in  cheese  made  by  a  milkman  in  whose  family 
diphtheria  was  present. 

Streptococci  may  contaminate  milk  and  a  series  of  basidiomycetes 
are  occasionally  found  in  it,  such  as  the  Amanita  muscara,  A.  verua, 
etc.,  which  are  lethal. 

A  mold,  the  Oidium  lacfis,  or  penicillium,  and  the  Bacterium 
cyanogenum  are  germs  which  produce  a  blue  color  in  milk  and 
sour  it.  The  mold  also  grows  upon  cream  cheese.  This  color 
appears  first  upon  the  surface  if  the  milk  be  not  agitated,  and  it 
differs  from  the  uniform  blue  imparted  by  adulteration  with  water, 
or  by  poisonous  plants,  drugs,  etc.  Milk  thus  affected  is  irritant, 
and  may  cause  febrile  gastritis,  stomatitis,  or  diarrhoea. 

Milk  is  colored  lemon  yellow  by  the  Bacterium  synxanthum 
(Ehrcnberg),  and  rod  by  chromogenic  fungi.  The  fungi  and  germs 


ANIMAL  FOODS  77 

themselves  do  not  impart  the  colors,  but  develop  various  anilines — 
aniline  blue,  fuchsin,  etc. — from  the  casein  (Schroter).  "  Clouty 
cream  "  is  produced  by  germ  action. 

5.  Souring. —  There  are  ten  different  varieties  of  bacteria  which  are 
capable  of  inciting  lactic-acid  fermentation  of  milk  sugar   (Leeds), 
all  of  which  cause  the  milk  to  "  sour "  and  curdle,  and  some,  but 
not  all,  simultaneously  develop  carbonic  acid  and  alcohol.     A  large 
proportion  of  the  bacteria  of  milk  rise  with  the  cream  to  the  surface 
(Freeman).     Milk   may   be   decomposing   although   it  has   not  yet 
coagulated.     The  first  process,  that  of  the  formation  of  lactic  acid,  is  a 
preliminary  to  the  normal  digestion  of  milk,  but  the  second  is  abnor- 
mal and  interferes  with  it.     The  sour  milk  curd  may  be  redissolved  by 
neutralization  with  alkalies. 

The  BaciUus  acidi  lactici  may  sour  the  milk  before  it  is  ingested, 
or,  like  many  germs,  their  action  may  not  be  apparent  before  swal- 
lowing the  milk,  but  it  begins  immediately  thereafter  in  the  stomach. 

Good,  clean,  uncontaminated  milk  should  keep  fresh,  exposed  in 
a  clean  room  at  the  ordinary  temperature  of  68°  F.  for  forty-eight 
hours  without  souring  and  coagulating.  But  if  the  air  is  much 
warmer,  or  if  the  milk  is  tainted  in  any  manner,  it  will  sour  in  a 
few  hours.  Boiled  milk  keeps  fresh  rather  more  than  half  as  long 
again  as  fresh  milk. 

6.  Odors. —  The  absorbent  power  of  milk  is  strong,  and  it  may 
acquire  a  strong  odor  from  substances  kept  in  its  vicinity.     It  may 
acquire  a  bad  flavor  at  the  same  time,  or  may  have  the  odor  alone. 

If  left  in  a  refrigerator  with  stale  cheese,  ham,  onions,  decompos- 
ing meats,  etc.,  it  soon  becomes  spoiled  in  this  manner.  Milk  easily 
absorbs  the  odor  of  tobacco,  camphor,  or  of  turpentine  from  fresh 
paint,  and,  in  fact  that  of  almost  any  volatile  substance.  It  should 
never  be  left  exposed  in  the  sick-chamber,  in  a  lavatory,  or  near  a 
waste  pipe. 

Prophylaxis  Against  Milk  Infection. —  As  prophylaxis  against 
milk  infection  certain  precautions  are  necessary,  and  it  should  be 
the  duty  of  physicians  to  educate  public  sentiment  in  regard  to  their 
importance  as  a  means  of  restricting  the  spread  of  infectious  and 
dietetic  diseases. 

For  transportation  from  the  country  to  the  city,  milk  is  usually 
taken  from  the  farms  in  forty-quart  tin  cans,  which  should  be  filled 
full  and  tightly  covered  to  prevent  churning  and  souring.  Some 
railways  supply  refrigerator  milk  cars,  which  are  hung  upon  spe- 
cially constructed  springs,  to  prevent  as  far  as  possible  agitation  of 
the  cans.  At  many  dairies  the  milk  is  put,  directly  after  milking, 


78 


FOODS  AND  FOOD  PREPARATIONS 


into  glass  bottles  previously  sterilized  by  washing  and  steaming, 
which  are  then  tightly  corked.  If  pails,  pans,  or  cans  are  used,  their 
absolute  cleanliness  should  be  insured  by  frequent  careful  washing 
and  by  occasional  scalding  with  hot  water.  This  destroys  germs  or 
ferments  which  would  otherwise  contaminate  the  fresh  milk  and 
soon  sour  it.  The  bottles  are  sealed  and  stamped  "  Certified  Milk  " 
before  being  sent  to  market. 

Nothing  is  more  disgusting  than  allowing  the  manure-besmirched 
tails  of  ungroomed  cows  to  contaminate  the  hands  of  milkers,  or  the 
milk  itself,  and  yet  this  is  constantly  happening. 


ABC 

FIG.  14. —  MODERN  MILKING  PAILS  TO  PREVENT  ACCESS  OF  DIBT. 
A,  Pail  into  which  the  udder  is  milked;  B,  Lid  of  A,  with  small  opening  at 
bottom  with  absorbent  cotton  used  as  strainer;   C,  Pail  to  set  in  cooler, 
with  vertical  glass  window  at  bottom,  and  faucet  to  draw  off  the  milk 
without  disturbing  cream  on  top. 
* 

The  question  of  prophylaxis  is  of  such  universal  interest  that 
the  admirable  rules  formulated  by  Vaughan  are  here  quoted  in  full: 

"  a.  The  cows  should  be  healthy,  and  the  milk  of  any  animal 
which  seems  indisposed  should  not  be  mixed  with  that  from  the 
healthy  animal. 

"  6.  Cows  must  not  be  fed  upon  swill  or  the  refuse  from  brew- 
eries or  glucose  factories,  or  upon  any  other  fermented  food. 

"  c.  Milch  cows  must  not  be  allowed  to  drink  from  stagnant  pools, 
but  have  access  to  fresh  pure  water. 

"  d.  The  pasture  must  be  freed  from  noxious  weeds,  and  the  barn 
and  yard  kept  clean. 


ANIMAL  FOODS  7 

"  e.  The  udders  should  be  washed  and  then  wiped  dry  before  each 
milking. 

"  /.  The  milk  must  be  at  once  thoroughly  cooled.  This  is  best 
done  in  the  summer  by  placing  the  milk  can  in  a  tank  of  cold  water 
or  ice  water,  the  water  being  of  the  same  depth  as  the  milk  in  the 
can.  It  would  be  well  if  the  water  in  the  tank  could  be  kept  flow- 
ing, and  this  will  be  necessary  unless  ice  water  is  used.  The  tank 
should  be  thoroughly  cleaned  each  day  to  prevent  bad  odors.  The 
can  should  remain  uncovered  during  the  cooling  and  the  milk  should 
be  gently  stirred.  The  temperature  should  be  reduced  to  60°  F.  or 
lower  within  an  hour.  The  can  should  remain  in  cold  water  until 
ready  for  delivery. 

"  g.  Milk  should  be  delivered  during  the  summer  in  refrigerated 
cans  or  in  bottles  about  which  ice  is  packed  during  transportation. 

"  li.  When  received  by  the  consumer  it  must  be  kept  in  a  clean 
place  and  at  a  temperature  some  degrees  below  60°  F. 

"  If  all  the  milk  used  in  the  artificial  feeding  of  infants  could  be 
obtained  and  marketed  with  the  care  demanded  by  the  above  rules, 
milk  infection  would  be  practically  unknown  and  the  sterilization 
of  the  infant's  food  would  be  unnecessary." 

Laws  relating  to  the  marketing  of  milk  have  been  enacted  in  39 
States,  which  comprise  such  improvements  as  are  summarized  in 
the  following  list,  compiled  by  the  Journal  of  the  American  Medical 
Association. 

"  The  registration  of  all  dairies ;  official  indorsement  of  prop- 
erly conducted  dairies;  inspection  of  all  herds,  barns,  dairy  build- 
ings, etc.,  once  a  month;  better  lighting,  ventilation,  drainage  and 
cleanliness  of  cow  stables;  whitewashing  the  interior  of  stables; 
eradication  of  tuberculosis  from  dairy  herds;  branding  of  condemned 
cows;  cows  not  to  be  given  swill  feed,  etc.;  cows  to  be  regularly 
cleaned;  pasturage  for  city  cows;  aeration  of  milk  in  pure  air;  prompt 
cooling  of  milk  and  holding  it  at  low  temperature  until  final  de- 
livery; shipment  of  milk  promptly  from  farms  after  milking;  de- 
livery of  milk  and  cream  in  sealed  packages  (glass  bottles  or  small 
cans),  so  as  to  avoid  unnecessary  contamination  by  city  dust,  etc.; 
delivery  of  milk  in  cities  at  any  hour  of  the  day  when  it  can  be 
supplied  in  the  best  condition;  restrictions  on  the  sale  of  milk  in 
markets,  candy  stores,  etc. ;  delivery  of  milk  from  such  stores  in 
bottles  only;  mixing  of  herd  milk  so  as  to  get  an  article  of  uniform 
composition;  bottling  of  milk  only  at  the  dairy  or  place  of  general 
supply;  daily  sterilization  of  milk  utensils;  more  rigid  inspection 


80 


FOODS  AND  FOOD  PREPARATIONS 


for  preservatives  in  milk;  chemical  and  bacteriologic  examinations 
of  milk;  standards  for  cream  and  skim  milk." 

The  enactment  of  these  laws  is  due  to  the  activity  of  the  medical 
profession,  and  has  been  largely  accomplished  through  the  influence 
of  County,  State,  or  other  medical  societies  and  boards  of  health 
which  latter  are  responsible  in  most  instances  for  their  enforcement. 

Guaranteed  or  Certified  Milk. — Quite  recently  Milk  Commissions 
have  been  established  which  undertake  to  supervize  the  methods  of 


FIG.  15. —  BOTTLING  ROOM  IN  A  HIGH-CLASS  CITY  DAIRY. 
(Dr.  Marcus  Benjamin,  Bui.  41,  Hygienic  Laboratory.) 

production  and  transportation  of  milk  and  guarantee  it's  purity  for 
consumers.  Such  a  Commission,  established  by  the  County  Medical 
Society  of  Xew  York,  comprizes,  besides  several  clinicians  especially 
interested  in  infant  feeding,  an  expert  chemist,  bacteriologist,  and 
veterinarian.  Similar  commissions  exist  in  several  large  cities 
throughout  the  country.  According  to  Ostheimer:  "Certified  milk 
must  be  free  from  pathogenic  microorganisms  and  contain  not  more 
than  from  10,000  to  30,000  to  the  c.c.  (varying  in  several  cities); 
its  specific  gravity  must  be  between  1,029  and  1,033;  its  reaction 
must  be  neutral  or  faintly  acid;  its  proteid  should  vary  between  3.5 
and  4  per  cent;  its  sugar  between  4.2  and  4.8  per  cent;  its  fat  be- 


ANIMAL  FOODS  81 

tween  3.5  and  4.5  per  cent ;  and  it  must  be  free  from  impurities,  col- 
oring matters  and  chemical  preservatives.  Besides,  the  condition  of 
the  dairy  and  the  cows  must  be  kept  excellent." 

Uses  of  Milk. —  The  following  are  the  more  important  uses  of 
milk:  1.  As  an  infant  food.  2.  As  a  food  for  adults.  3.  As  a 
source  of  special  food  products  and  derivatives,  such  as  koumiss, 
cream,  butter,  and  cheese.  4.  As  a  diuretic.  5.  For  its  soothing 
effect  on  diseased  mucous  membranes  of  the  alimentary  canal.  6. 
To  loosen  cough  (when  given  hot).  7.  As  a  prophylactic  against 
lead  poisoning.  8.  As  a  vehicle  for  the  administration  of  other 
foods.  9.  As  a  vehicle  for  the  administration  of  medicines.  10. 
For  rectal  injection. 

The  first  three  of  these  uses  are  so  important  that  they  will  receive 
separate  detailed  consideration  (see  Diet  in  Infancy,  and  Adaptation 
of  Milk  for  the  Sick,  page  84,  and  Milk  Derivatives,  page  108)  ;  the 
others  are  referred  to  briefly  here. 

4.  The  diuretic  action  of  milk  in  some  persons  is  very  pronounced, 
while  in  others  it  is  not  noticeable.     It  is  due  to  the  two  ingredients, 
water  and  lactose  or  milk  sugar.     The  water  acts  by  increasing  the 
volume  of  blood  and  the  renal  blood  pressure.     The  lactose  probably 
acts  directly  by  stimulating  the  renal  epithelium.     Lactose  has  been 
employed  with  doubtful  success  as  a  diuretic  in  dropsies  and  some 
forms  of  renal  disease.     The  dose  for  this  purpose  is  twenty  to  thirty 
grains. 

The  mineral  salts  and  the  water  of  milk  are  speedily  absorbed 
by  the  mucous  membrane  of  the  stomach,  and  in  some  persons  this 
process  is  so  rapid  that  milk  taken  by  the  tumblerful  into  an  empty 
stomach  has  a  very  decided  diuretic  effect  within  an  hour.  This 
action  may  be  promoted  by  drinking  a  cup  of  black  coffee. 

5.  Milk  is  soothing  to  the  mucous  membranes  of  the  alimentary 
canal.     It  is  often  the  only  variety  of  food  which  can  be  borne  by 
an   inflamed   or   irritable   stomach   or   in   some   forms   of   intestinal 
disease.     It  is  equally  soothing  in  the  rectum. 

6.  A  few  sips  of  hot  milk  or  hot  milk  and  Vichy  will  often  allay 
an  irritable  cough,  and  favor  the  expectoration  of  tenacious  bronchial 
mucus. 

7.  Milk    is    sometimes    employed    among    type    founders'   as    pro- 
phylactic against  lead  poisoning.     It  is  claimed  by  Hirt  that  if  a 
quart  or  two  be  drunk  daily,  poisoning  never  occurs. 

8.  As  a  vehicle  for  administration  of  other  foods  for  invalids,  such 
as  egg  albumen,  beef-meal,  meat  juice,  peptonoids,  cocoa,  spirits,  etc., 
milk  is  most  useful. 


FOODS   AND   FOOD   PREPARATIONS 

9.  As  a  vehicle  for  the  administration  of  many  medicines  and 
insoluble  powders,  such  as  calomel,  disagreeable-tasting  drugs,  like 
potassium  iodide,  salicylates,  opium,  etc.,  milk  is  often  very  service- 
able.    Sulphonal,  trional  and  veronal  given  in  hot  milk  act  better 
than  if  prescribed  alone. 

10.  Milk  as  an  ingredient  of  nutrient  enemata  is  described  on 
page  457. 

Attempts  to  get  milk  into  the  circulation  by  rubbing  it  into  the 
skin  and  by  soaking  portions  of  the  body  in  milk  baths  have  proved 
of  no  avail,  for  it  is  not  absorbed  in  that  manner. 

The  intravenous  injection  of  milk  has  been  used  occasionally  in 
cholera  collapse,  post-partum  hemorrhage,  etc.,  and  in  some  few 
cases  it  has  been  found  satisfactory,  but  since  saline  injections  have 
proved  more  efficacious,  those  of  milk  have  been  abandoned.  Milk 
has  also  been  injected  into  the  peritoneal  cavity,  but  without  much 
benefit.  It  has  been  given  hypodermically  in  doses  of  four  grams,  (3i) 
(Menzel).  One  patient  was  kept  alive  sixty-three  days  in  this  man- 
ner (Whittaker).  The  milk  thus  injected  is  absorbed  within  an  hour. 

Milk  Digestion. —  Normal  Digestion. —  Milk  is  not  altered  in  the 
mouth,  but  on  reaching  the  stomach  the  casein  is  precipitated  by  the 
curdling  ferment,  called  rennin.  The  curds,  or  coagulse,  vary  in  size 
and  toughness  according  to  the  quality  of  the  milk,  its  degree  of 
dilution,  and  other  circumstances. 

The  gastric  hydrochloric-acid  also  coagulates  milk  by  neutraliz- 
ing the  alkali  which  holds  the  casein  in  solution.  Hence  milk  be- 
comes really  a  solid  food  almost  as  soon  as  it  enters  the  stomach. 
In  coagulating,  the  curds  entangle  the  fat  globules,  but  the  curds  are 
soon  dissolved  by  the  ferment  of  the  gastric  juice  (pepsin)  and  con- 
verted into  albumoses.  The  fat  globules  are  again  liberated,  their 
albuminous  envelopes  are  dissolved,  and  they  coalesce  to  larger  drop- 
lets, in  which  condition  they  pass  with  the  chyme  into  the  intestine. 
The  usual  period  for  the  complete  digestion  of  milk  in  the  stomach 
by  normal  gastric  juice  occupies  about  three  hours. 

The  salts  and  water  of  the  milk,  and  possibly  to  some  extent  the 
sugar,  are  absorbed  in  great  part  from  the  stomach  wall.  In  proof 
of  this  is  the  fact  that  the  diuretic  action  of  milk  is  often  obtainable 
within  half  the  time  required  for  the  complete  digestion  of  the  al- 
buminoids. When  not  absorbed  by  the  stomach  they  pass  into  the 
intestine  and  are  absorbed  through  the  villi. 

Those  curds  which  are  not  fully  dissolved  by  the  gastric  juice 
enter  the  duodenum,  where  their  digestion  is  completed  by  the 
pancreatic  juice.  The  latter  saponifies  the  fat  which  is  absorbed  by 


ANIMAL  FOODS  83 

the  lacteals  of  the  villi.  In  the  digestion  experiments  of  C.  H.  Woods 
and  L.  H.  Merrill  (U.  S.  Department  of  Agriculture  Bulletin)  the 
digestibility  of  milk  casein  was  always  increased  by  the  addition  of 
bread  to  the  milk. 

Rennin. —  Rennet  is  the  name  given  to  an  infusion  of  the  middle 
stomach  of  the  calf  in  brine  which  possesses  special  milk-curdling 
power  which  is  due  to  a  ferment  called  rennin. 

This  milk-curdling  ferment  is  believed  to  be  developed  by  the 
action  of  acids  from  an  antecedent  material  called  zymogen.  Rennin 
is  not  obtainable  from  the  human  stomach  in  large  quantity,  but  it 
undoubtedly  exists  in  gastric  juice,  for  pure  pepsin  has  scarcely 
any  curdling  action  upon  milk;  moreover,  milk  may  curdle  in  either 
neutral  or  alkaline  media  in.  which  pepsin  is  inert.  Rennin  is  most 
active  in  an  acid  medium,  but  it  also  works  in  the  alkaline  pancre- 
atic juice.  Ii>  possesses  little  proteolytic  power.  It  exists  more 
abundantly  in  the  infant  stomach  than  in  that  of  the  adult. 

Rennet  may  be  prepared  as  a  powder;  it  is  sold  by  grocers  in 
alcoholic  solution,  and  when  added  to  milk  which  is  gently  warmed,  a 
light  coagulum  is  formed,  causing  the  milk  to  partially  solidify.  The 
coagulum  contracts  and  squeezes  out  fluid,  which  constitutes  whey. 
The  rennetized  milk  when  flavored  with  vanilla  or  powdered  cinna- 
mon or  nutmeg  makes  an  agreeable  invalid  food  or  dessert  called 
"  junket,"  which  is  highly  nutritious,  for  it  contains  all  the  valuable 
ingredients  of  milk. 

Abnormal  Digestion. —  In  cases  of  indigestion  from  various  causes 
tough  casein  curds  may  remain  undissolved  in  the  stomach,  eventually 
irritating  it  and  causing  vomiting,  or  they  may  pass  along  the  intestine 
and  be  voided  unaltered  in  the  stools.  This  occurrence  is  more  fre- 
quently noticed  in  young  infants  than  in  adults.  But  the  "  curds  " 
found  in  infant  stools  often  are  composed  not  of  casein,  but  of 
saponified  fat  with  bacteria  (see  p.  57). 

Many  substances  may  be  added  to  milk  which  by  their  mechanical 
presence  will  prevent  the  formation  of  tough  curds.  Excessive  acidity 
of  the  stomach  due  either  to  hypersecretion  of  hydrochloric  acid  or 
the  presence  of  organic  acids,  especially  lactic,  derived  from  the  food 
or  fermentation  processes,  modifies  the  digestion  of  milk;  the  lactose 
is  altered  into  lactic  acid  and  the  casein  promptly  coagulated.  The 
alkaline  salts  of  milk  are  split  up  and  phosphoric  acid  is  liberated, 
and  complicated  fermentative  changes  ensue  which  are  as  yet  im- 
perfectly understood.  All  this  causes  more  or  less  gastroenteric  ir- 
ritation, resulting  in  diarrhoea. 

When  milk  or  cheese  remains  too  long  in  the  stomach  or  intes- 


84  FOODS  AND  FOOD  PREPARATIONS 

tine  a  further  fermentation  is  excited  accompanied  by  a  neutral  or 
alkaline  reaction,  and  which  results  in  the  final  production  of  butyric 
acid,  and  sometimes  of  other  substances,  such  as  leucin,  tyrosin,  and 
ammonia.  But  while  free  hydrochloric  acid  exists  in  the  contents  of 
the  stomach,  the  organic  acids  —  lactic,  butyric  and  acetic  —  which  are 
associated  with  milk  fermentation  are  unlikely  to  develop. 

Cow's  milk  readily  may  become  acid  from  alteration  in  the  rela- 
tive amount  of  potassium  biphosphate  and  the  two-thirds  phosphate 
of  potassium.  The  former,  if  present  in  excess,  hastens  coagulation 
and  an  acid  reaction.  When  warm  the  milk  again  may  become  alka- 
line (Soxhlet,  Heintz). 

These  facts  explain  the  frequent  necessity  of  using  antacids,  such 
as  lime  water  or  sodium  bicarbonate,  with  infant  milk  food.  Mucous 
fermentation  of  the  proteids  makes  the  milk  slimy,  and  it  becomes 
stringy  on  boiling. 

Milk,  according  to  Buhner's  experiments,  yields  more  bulky  resi- 
due in  the  feces  than  either  eggs  or  meat,  yet  its  nutritive  ingredi- 
ents are  sufficiently  absorbed.  This  is  well  illustrated  in  the  ex- 
clusive milk  diet  of  typhoid  fever.  From  8  to  10  per  cent  approxi- 
mately of  the  solids  of  milk  are  eliminated  in  the  stools. 

ADAPTATION   OF  MILK  FOE  THE  SICK 

AVhen  patients  object  to  the  taste  of  milk  alone,  they  may  be 
induced  to  take  large  quantities  by  using  it  in  various  combinations 
or  preparations,  or  by  disguising  its  taste.  Many  patients  when  or- 
dered a  milk  diet  positively  assert  that  they  cannot  endure  the  taste 
of  milk;  that  it  always  nauseates  them,  or  that  it  makes  them  bilious 
and  constipated,  and  excites  headache.  They  say,  perhaps,  that  they 
have  faithfully  tried  to  drink  it  before,  and  never  could  tolerate  it ;  but 
scarcely  any  one  person  has  ever  tried  all  the  different  methods  of 
taking  milk,  and  it  does  not  follow  that  because  it  once  disagreed 
several  years  before  it  will  again.  The  objection  to  the  taste  may 
be  overcome  by  a  little  tact  and  perseverance,  and  there  are  very 
few  persons  who  cannot  assimilate  a  more  or  less  exclusive  milk 
diet  if  the  milk  is  given  properly,  and,  if  necessary,  artificially  di- 
gested for  them.  Their  previous  unhappy  experience  is  probably  due 
to  having  taken  a  large  dose  of  undiluted  rich  milk,  which  promptly 
coagulated,  soured,  and  was  rejected,  exciting  all  the  distaste  which 
they  have  treasured  against  it. 

When,  as  in  some  febrile  cases  or  in  acute  Bright's  disease,  a  milk 
diet  is  imperative,  such  patients  should  begin  with  a  teaspoonful 


ANIMAL  FOODS  85 

or  two  at  a  time,  repeating  it  once  in  ten  or  fifteen  minutes.  If  milk 
is  only  taken  slowly  enough  into  the  stomach,  and  mingled  on  the 
way  with  saliva,  like  other  food  —  eaten  rather  than  drunk  —  it  is  im- 
possible for  it  to  form  the  large  tough  curds  that  it  does  when  poured 
down  by  the  tumblerful. 

In  all  cases  where  there  is  tendency  for  milk  to  disagree  it  is 
better  to  give  it  alone  to  the  patient,  by  which  means  various  expe- 
dients used  to  increase  its  digestibility  may  better  be  tested.  Patients 
will  often  digest  both  milk  and  beef  broth  or  milk  and  whisky  when 
these  substances  are  given  at  alternating  intervals  of  one  or  two 
hours,  whereas  if  taken  in  conjunction  they  give  rise  to  dyspepsia. 

The  methods  of  altering  milk  to  suit  the  taste  or  digestive  re- 
quirements are  so  numerous  that  it  will  be  found  convenient  to  group 
them  under  the  following  headings,  although  the  classifications  are 
somewhat  arbitrary  and  here  and  there  may  overlap : 
I.  Methods  of  altering  the  taste  of  milk. 
II.  Methods  of  improving  the  digestibility  of  milk. 

III.  Methods  of  predigestion. 

IV.  Methods  of  sterilization,  pasteurization  and  preservation. 

The  first  method  beguiles  the  patient  into  taking  larger  quantities 
of  milk  without  tiring  of  it;  the  second  aims  at  preventing  the  for- 
mation in  the  stomach  of  dense  tough  coagula?  which  are  difficult  of 
solution  and  digestion  by  an  enfeebled  gastric  juice;  the  third,  by 
artificial  digestion,  relieves  a  weak  stomach  of  much  labor;  the 
fourth  prevents  the  accession  of  poisonous  germs  which  would  excite 
malfermentation  and  indigestion. 

I.  Methods  of  Altering  the  Taste  of  Milk 

When  patients  object  to  the  taste  of  raw  milk  or  tire  of  it,  it  may 
be  flavored  in  a  variety  of  ways.  When  there  is  no  objection  on 
the  score  of  the  nervous  system,  a  teaspoonful  or  two  of  black  coffee 
is  one  of  the  best  means  at  hand,  or  a  little  of  the  extract  of  coffee 
may  be  added.  Very  weak  tea  may  be  preferred.  Caramel  is  an- 
other excellent  flavoring  substance  which  may  be  freely  employed, 
and  ginger  is  also  used.  Other  patients  may  take  a  little  chocolate 
or  cocoa  or  cocoa  nibs  infusion  with  their  glass  of  milk.  Some 
prefer  the  addition  of  common  salt  or  a  little  black  pepper.  The 
various  meat  extracts,  fluid  or  solid  (see  Meat  Preparations,  p.  132), 
may  be  used  to  advantage.  When  alcohol  is  not  contraindicated  many 
patients  are  willing  to  drink  much  milk  in  the  form  of  weak  punches, 
or  as  eggnog  in  which  cognac,  whisky,  sherry,  or  rum  may  be  em- 
ployed to  disguise  the  "  flat  "  milk  taste. 


86  FOODS  AND  FOOD  PREPARATIONS 

The  various  malt  extracts  are  enjoyed  by  some  when  given  in 
milk,  and  their  disagreeable  sweetness  is  thereby  removed.  A  tea- 
spoonful  of  malt  may  be  added  to  a  pint  of  milk  which  is  gently 
warmed  for  half  an  hour,  after  which  it  is  boiled  for  twenty  minutes. 
This  prevents  the  formation  of  large  curds. 

None  of  these  additions  materially  affect  the  nutritive  value  of 
milk,  and  the  occasional  variety  which  may  be  secured  by  experi- 
menting with  different  substances  will  usually  overcome  all  preju- 
dice. I  often  have  induced  patients  to  take  large  quantities  of 
junket  flavored  with  a  little  spice  (see  Receipts  for  Invalid  Foods), 
not  realizing  that  they  were  really  eating  only  pure  milk  which  had 
passed  into  the  first  stage  of  digestion.  Patients  who  object  to  milk 
because  they  have  to  drink  so  much  fluid  may  take  the  same  quan- 
tity in  the  form  of  junket  because  they  can  eat  it  with  a  spoon. 

Much  milk  may  be  disguised  sometimes  in  custards,  gruels,  blanc- 
mange, etc.,  where  there  is  no  objection  to  the  addition  of  other 
easily  digestible  foods. 

II.  Methods  of  Improving  the  Digestibility  of  Milk 
1.  Skimming.     2.  Boiling.     3.  Dilution   with   water.     4.  Dilution 
with  alkaline  and  aerated  waters.     5.  Dilution  with  amylaceous  foods. 
6.  Addition  of  alkalies,  acid  and  other  substances. 

1.  Skimmed  milk  is  the -residue  after  removal  of  the  cream.     It 
contains  water,  90.63  per  cent;  proteid,  3.06  per  cent;  fat,  0.79  per 
cent;  sugar,  4.77  per  cent,  and  a  residue  of  salts.     It  thus  retains 
almost  10  per  cent  of  solids. 

Skimmed  milk  is  well  digested  by  those  patients  whose  stomachs 
do  not  tolerate  fat  in  any  form,  but  it  will  not  long  support  life  (see 
"Skimmed  Milk  Cure"). 

Yeo  advises  gouty  subjects  to  drink  ten  minutes  before  each  meal 
a  breakfastcupful  (eight  ounces)  of  hot  skimmed  milk  and  water  with 
the  addition  of  a  small  saltspoonful  each  of  potassium  bicarbonate 
and  salt.  This  is  a  good  means  of  prescribing  an  alkali,  but  there 
is  no  specific  advantage  in  the  skimmed  milk. 

2.  Boiling. —  Boiled  milk  exhibits  a  thin  scum  of  albumin  upon  the 
surface  which  entangles  some  of  the  fat  globules,  and  which  is  quickly 
replaced  by  another  after  removal.     This  scum  should  not  be  served 
to  invalids.     There  is  much  discussion  as  to  whether  infants  should 
over  be  given  raw  cow's  milk,  or  only  that  which  previously  has  been 
boiled,  and  authorities  are  divided  upon  the  matter.     Certainly  in 
most  eases  raw  milk,  if  pure,  provokes  no  harm.     Boiling  the  milk 
arrests  the  development  of  germs  and  fungi  with  which  it  may  have 


ANIMAL  FOODS  87 

become  contaminated,  and  thus  may  prevent  the  spread  of  some 
diseases,  and  it  retards  the  process  of  "  souring "  and  coagulation. 
Boiling  expels  about  3  per  cent  of  gases  —  carbon,  nitrogen,  and 
oxygen  —  and  the  loss  of  oxygen  diminishes  the  formation  of  lactic- 
acid  and  consequent  souring.  It  alters  the  taste  of  the  milk  some- 
what, and  makes  it  "flat."  The  flatness  is  removed  by  agitating 
the  milk  with  air  by  pouring  it  back  and  forth  into  two  cups  held 
a  little  distance  apart;  or  it  may  be  removed  by  addition  of  soda, 
selzter,  carbonic  water  or  Apollinaris.  As  a  rule,  boiled  milk  is  pre- 
ferred hot,  but  some  persons  enjoy  it  cold. 

It  is  a  prevalent  idea  that  milk  is  in  general  more  digestible  if 
boiled  than  if  raw,  but  the  results  of  experiment  do  not  wholly 
confirm  this  view.  Crolas  has  demonstrated  that  boiling  has  no 
influence  upon  either  the  lactose  or  casein,  but  it  slightly  increases 
the  free  soluble  phosphates,  which  he  regards  as  an  advantage. 

Occasionally  patients  are  made  bilious  and  constipated  by  the  use 
of  boiled  milk  who  digest  it  better  raw,  but  the  converse  is  also  true : 
it  is  a  matter  of  idiosyncrasy.  It  has  decided  advantage  in  diar- 
rhceal  diseases,  probably  through  the  absence  of  germs  and  gases. 
In  some  cases  it  may  be  combined  with  thin  chocolate  or  cocoa. 

"  Scalded  milk  "  is  heated  to  about  150°  F.,  or  practically  "  pas- 
teurized," by  pouring  on  boiling  water.  Thus  treated,  milk  remains 
fresh  a  little  longer  than  when  raw. 

3.  Dilution  with  Water. —  Plain  water,  either  hot  or  cold,  may  be 
added  in  proportion  of  one  part  to  two  or  three  of  milk.     If  the  milk 
is  exceptionally  rich  in  cream  and  casein  this  simple  means  often  will 
be  sufficient  to  ensure  its  better  digestion,  for  the  curds  become  both 
smaller  and  softer. 

4.  Dilution  with  Alkaline  or  Aerated  Water. —  Lime  water  may  be 
added  in  the  proportion  of  two  to  four  or  more  tablespoonfuls  to 
each  tumblerful  of  milk,  taken  cold.     In  cases  with  much  acidity  of 
the  stomach  the  lime  water  should  be  mixed  in  the  proportion  of  one- 
half  or  two-thirds.     When  so  given,  the  taste  of  the  milk  is  so  little 
altered  that  very  few  patients  object  to  it,  and  some  find  it  more 
agreeable.     If  diarrhoea  or  nausea  is  present  they  are  controlled  to 
some   extent,  but  on  the  other  hand  constipation  is   increased  by 
the  use  of  lime.     When  the  latter  exists  it  is  better  to  dilute  with 
aerated  water.     If  lime  water  is  added  to  neutralize  the  acidity  of 
cow's  milk  the  temperature  of  the  mixture  should  not  be  raised  above 
that  of  pasteurization  —  160°  F. —  because  the  albuminoids  are  more 
or  less  decomposed  in  boiling  alkaline  solution.     It  is  better  to  sep- 
arately pasteurize  the  milk  and  add  the  lime  water  afterwards. 


88          FOODS  AND  FOOD  PREPARATIONS 

Barley  water  may  be  used  as  a  diluent  for  milk  in  diarrhoea,  but 
oatmeal  water  is  better  if  there  is  constipation. 

Aerated  waters,  such  as  carbonic-acid  water,  alkaline  Vichy,  Seltzer, 
bottled  plain  soda,  or  Apollinaris,  all  may  be  added  to  milk,  in  any 
desired  proportion.  In  cases  of  fever  four  ounces  of  a  mixture  made 
with  equal  parts  of  the  diluent  may  be  given  every  hour,  or  eight 
ounces  every  two  hours,  up  to  three  and  a  half  or  four  pints  of  milk 
per  diem.  Most  of  these  waters  are  used  best  with  cold  milk,  but 
for  many  persons  hot  milk  and  Vichy  make  a  very  agreeable  combina- 
tion, which  is  often  soothing  to  the  obstinate  cough  of  bronchitis. 
The  mixtures  with  Vichy  and  lime  water  are  especially  serviceable 
where  extreme  irritability  of  the  stomach  is  present  with  a  tendency 
to  the  immediate  rejection  of  all  fluids. 

5.  Dilution  with  Amylaceous  Foods. —  Any  form  of  starchy  food  — 
flour,  arrowroot,  etc. —  serves  as  a  mechanical  diluent  of   milk  by 
mingling  with  it  and  preventing  the  precipitation  of  tough  curds. 
Bread  and  milk,  rice  or  crackers  and  milk,  serve  the  same  purpose, 
and   have  the  further  advantage  that  they  must  be  eaten  slowly  and 
mixed  with  saliva. 

When  infants  vomit  their  milk  it  may  be  attenuated  temporarily 
with  either  barley  water  or  oatmeal  water  added  instead  of  plain 
water,  and  in  the  same  proportion  —  i.  e.,  one-third  or  one-half.  The 
much-extolled  starchy  "infant  foods"  are  less  useful  as  foods  than 
they  are  diluents  of  milk,  and  if  used  temporarily  with  the  latter 
object  solely  in  view,  are  less  liable  to  produce  rickets,  scurvy, 
or  gastric  catarrh.  Whenever  amylaceous  substances  are  selected  to 
dilute  milk  for  infants  they  first  should  be  converted  as  far  as  possi- 
ble into  dextrin  and  glucose,  for  gummy  dextrin,  saccharine,  or 
gelatinous  materials  are  all  better  than  crude  starchy  foods.  For 
adults  a  tablespoonful  of  Mellin's  or  Nestle's  food  or  Imperial  Granum 
dissolved  in  an  ounce  of  hot  water  and  added  to  a  glass  of  milk  is 
both  palatable  and  nutritious  in  cases  of  phthisis  or  scrofula. 

6.  Addition  of  Alkalies,  Acid  and  Other  Substances. —  The  addition 
of  alkalies  to  milk  renders  it  much  more  digestible  for  some  persons. 
In  hyperacidity  of  the  stomach  or  in  the  presence  of  abnormal  fer- 
mentation alkalies  are  beneficial  as  neutralizing  agents.     On  the  other 
hand,  in  cases  in  which  the  gastric  juice  is  very  feeble  or  absent, 
artificially  digested  milk  may  prove  more  serviceable.     The  admix- 
ture of  alkalies  by  reducing  the  acidity  of  the  gastric  juice  makes 
the  easein  coagulate  more  slowly,  and  in  flocculi  rather  than  in  large 
coagulae. 

Salt  may  be  added  —  a  saltspoonful  to  the  tumbler  of  milk.     This 


ANIMAL  FOODS  89 

improves  its  digestibility  for  most  persons,  and  renders  it  less  likely 
to  cause  biliousness.  Sodium  bicarbonate,  ten  grains,  or  a  salt- 
spoonful  to  the  tumbler  of  milk,  prevents  malfermentation  in  the 
stomach.  If  hyperacidity  of  the  stomach  exist  sodium  bicarbonate 
may  prove  better  than  lime  water,  which  is  only  slightly  antacid,  for  it 
contains  a  half  grain  of  lime  to  the  ounce.  On  the  other  hand, 
if  the  gastric  juice  is  too  feeble  to  digest  milk  easily,  it  is  sometimes 
a  disadvantage  to  attenuate  it  still  further  with  quantities  of  lime 
water,  and  sodium  bicarbonate  should  be  substituted  to  check  the 
lactic-acid  fermentation  of  the  milk  which  the  hydrochloric  acid  of 
the  gastric  juice  fails  to  control.  An  excellent  combination  for  an 
irritable  stomach  is  made  by  adding  five  or  ten  grains  of  this  salt  and 
two  grains  of  cerium  oxalate  to  each  glass  of  milk.  The  cerium  oxa- 
late  has  a  sedative  and  tonic  action  upon  the  mucous  membranes  and 
tends  to  allay  nausea  and  irritation  in  the  stomach. 

Other  substances  sometimes  added  in  cases  of  gastric  ulcer,  etc.,  are 
sodium  phosphate,  saccharated  lime,  or  a  teaspoonful  of  milk  of 
magnesia  to  the  pint.  A  few  drops  of  liquor  potassae  to  the  pint  of 
milk  are  recommended  by  Bulkley  for  infants  having  eczema. 

Starr  gives  the  following  receipt  for  making  saccharated  lime  for 
diluting  milk  for  infants: 

Slaked  lime,  one  ounce;  refined  powdered  sugar,  two  ounces; 
mix,  triturate,  add  distilled  water,  one  pint.  Shake  occasionally  for 
some  hours  in  a  bottle,  let  stand,  and  siphon  out  the  fluid. 

Roberts  recommends  a  powder  containing  10  grains  each  of  so- 
dium bicarbonate  and  common  salt,  and  5  grains  of  light  magnesia, 
to  be  added  to  a  tumblerful  of  one-third  hot  water  and  two-thirds 
hot  milk. 

Edes  strongly  recommends  the  addition  of  hydrochloric  acid  to 
milk.  Twenty  minims  of  the  dilute  acid  of  the  pharmacopoeia  are 
stirred  slowly,  drop  by  drop,  into  a  pint  of  milk  which  is  gently 
warmed.  A  fine  flocculent  coagulum  of  casein  floats  in  the  whey,  the 
digestibility  of  the  milk  is  improved,  and  a  flat  or  disagreeable  taste  is 
avoided. 

Gelatin. —  Gelatin  may  be  employed  in  small  quantity  as  an  at- 
tenuant  of  milk.  Starr  gives  the  following  receipt  for  its  use : 

Soak  a  piece  of  white  gelatin  an  inch  square  in  half  a  cupful  of 
cold  water  for  three  hours.  Put  the  cup  in  a  saucepan  of  water  and 
boil  until  the  gelatin  dissolves.  When  cold  it  forms  a  jelly.  For 
infants  one  or  two  teaspoonfuls  may  be  put  into  each  nursing  bottle  of 
milk. 


90          FOODS  AND  FOOD  PREPARATIONS 


III.  Methods  of  Predigestion,  Sour  Milk,  " Koumiss"  etc. 

1.  Peptonized  milk.  2.  Pancreatinized  milk.  3.  Sour  milk,  kou- 
miss, kefir,  zoolak,  etc. 

1.  Peptonized  Milk. —  The  object  of  peptonizing  milk  is  to  com- 
plete a  portion  of  the  digestive  process  outside  of  the  body,  and  thereby 
relieve  the  alimentary  canal  of  this  work. 

Powdered  pepsin  may  be  added  some  time  before  the  milk  is  swal- 
lowed, and  in  this  event  it  can  act  only  in  conjunction  with  dilute 
hydrochloric  acid.  If  added  to  the  milk  at  the  time  of  swallowing,  the 
normal  acid  of  the  gastric  juice  supplies  the  proper  reaction. 

The  process  of  artificial  peptonizing  consists  in  adding  one  of 
the  numerous  preparations  of  pepsin  obtained  at  the  pharmacist's  to 
fresh  acidulated  milk,  and  allowing  it  to  stand  in  a  bottle  immersed 
in  warm  water  at  approximately  the  body  temperature.  Fermenta- 
tion results  in  which  the  casein  is  more  or  less  completely  converted 
into  albumoses.  If  the  process  be  too  long  continued,  further  fer- 
mentation results,  and  the  milk  becomes  very  bitter.  It  is  therefore 
checked  after  a  few  minutes,  either  by  boiling  the  milk,  which  has  the 
effect  of  destroying  the  pepsin,  or  by  keeping  it  upon  ice  until  ready  for 
use,  which  inhibits  the  action  of  the  ferment. 

Either  peptonized  or  pancreatinized  milk  may  be  prepared  in 
quantity  for  use  by  infants  or  invalids  during  the  day,  and  if  there 
is  an  ice  chest  to  keep  it  in,  it  is  better  to  do  so,  for  then  it  is  more 
uniform  in  composition.  If  ice  is  not  at  hand,  the  preparation 
should  be  made  fresh  for  use  each  time,  otherwise  it  will  become  bitter 
and  spoil. 

2.  Pancreatinized  Milk. —  The  use  of  pepsin  for  predigestion  of 
milk  has  been  superseded  gradually  by  that  of  pancreatin,  which  acts 
best  in  an  alkaline  medium.     This  ferment,  like  pepsin,  may  be  pre- 
served almost  indefinitely  in  powdered  form.     Milk  thus  prepared  is 
slightly  yellow  and  less  opaque  than  raw  milk.     The  process  may  be 
conducted  as  follows : 

Add  a  pint  of  fresh  milk  to  a  gill  of  cold  water  in  a  clean  ves- 
sel. Put  in  a  tubeful  of  Fairchild's  "  peptonizing  powder  "  (pancre- 
atic extract  5  grains,  and  sodium  bicarbonate  15  grains),  or,  instead 
of  the  pancreatic  extract,  substitute  1  to  2  drachms  of  "pancreatic 
solution  "  made  by  Parke,  Davis  &  Co.,  stir  well,  and  place  in  warm 
(not  boiling)  water  for  half  an  hour  or  until  a  slight  bitter  taste  is 
present.  This  taste  means  that  fermentation  has  proceeded  far 
enough.  To  allow  it  to  continuue  will  make  the  milk  unpalatable, 


ANIMAL  FOODS  91 

and  it  is  almost  impossible  to  disguise  the  bitterness.  Boiling  for  two 
or  three  minutes  stops  further  fermentation,  and  the  milk  should  then 
be  placed  on  ice  until  ready  for  use.  Such  milk  will  keep  well  for 
several  hours.  When  used,  serve  alone  cold,  or  add  carbonic-acid 
water  to  improve  the  taste.  For  adults  a  little  coffee  may  be  used 
for  the  same  purpose.  A  receipt  for  pancreatinized  milk  gruel  is 
given  under  Eeceipts  for  Invalid's  Food. 

When  pancreatinization  is  long  continued  the  casein  is  completely 
digested,  but  the  milk  becomes  too  bitter  for  use. 

Legumin. — Legumin  is  a  vegetable  ferment  which  is  said  to  make 
milk  highly  digestible  for  invalids  by  converting  casein  into  a  sol- 
uble albuminoid.  This  substance,  which  was  lately  introduced  by 
Bovet,  is  also  given  as  a  food. 

Sour  Milk. —  Sour  whole  milk  differs  from  buttermilk  in  that  the 
fat  has  not  been  removed.  The  "  souring  "  is  due  to  development  of 
lactic  acid  through  the  agency  of  lactacid  bacilli.  One  variety  of 
these,  the  rod-shaped  Bacillus  Bulgaris,  or  Bulgaricus  (derived  from 
milk  soured  in  Bulgaria),  is  most  active  in  developing  lactic  acid. 
According  to  Elie  Metchnikoff,  of  the  Paris  Institut  Pasteur,  this 
bacillus  colonizes  in  the  intestine,  and  causes  an  acid  reaction  which  is 
inimical  to  the  growth  of  putrefactive  organisms,  such  as  produce 
butyric  acid,  indol,  skatol,  etc.  This  antagonistic  action  of  the 
lactacid  bacilli  to  putrefaction  was  first  demonstrated  by  C.  H. 
Herter  of  Xew  York  in  1897.  Metchnikoff  in  his  Essais  Optimistes 
(1907)  and  "The  Prolongation  of  Life"  (1908)  advances  the  theory 
that  the  putrefactive  products  of  the  intestine  being  absorbed,  im- 
pair vitality  and  tend  to  shorten  life,  and  that  by  consuming  an  ex- 
cess of  the  lactacid  bacilli,  these  abnormal  processes  may  be  checked 
and  life  prolonged.  He  states  that  "this  variation  of  the  intestinal 
microbes  in  its  relation  to  our  foods  permits  us  to  modify  the  in- 
testinal flora  by  replacing  harmful  microbes  with  those  that  are  use- 
ful/' In  support  of  this  theory,  Metchnikoff  adduces  many  historical 
facts.  Sour  milk  is  mentioned  favorably  as  an  article  of  diet  in  the 
Bible  (Genesis  xviii,  8;  and  Deuteronomy  xxxii,  14)  and  to  this  day 
constitutes  a  staple  food  among  many  peoples  in  parts  of  Africa, 
Eastern  Europe  and  Asia.  Many  instances  of  extreme  old  age 
(vigorous  old  age),  have  been  found  among  habitual  users  of  sour 
milk.  Metchnikoff  writes: 

"  I  have  learned  a  very  important  fact  from  Charcot.  During  his 
stay  of  sixteen  months  in  the  Antarctic  regions,  neither  he  nor  his  crew 
ate  any  food  save  that  which  was  sterilized.  Their  bill  of  fare  con- 
sisted of  preserves  of  all  kinds,  together  with  the  cooked  flesh  of  seals, 


92          FOODS  AND  FOOD  PREPARATIONS 

penguins,  etc.  They  ate  no  raw  vegetables  or  fruits,  and,  save  a  small 
quantity  of  cheese,  their  diet  was  strictly  aseptic.  The  whole  per- 
sonnel of  this  expedition  enjoyed  most  excellent  health  and  in  no 
instance  was  there  a  single  case  of  derangement  of  the  digestion." 

"  In  many  countries,  particularly  in  Eussia,  vegetables  that  have 
undergone  an  acid  transformation  form  a  large  portion  of  the  food 
of  the  population.  During  the  long  winter,  in  default  of  fresh  fruits 
and  vegetables,  preserves  of  watermelon,  cucumbers,  apples  and  other 
fruits  that  have  been  subjected  to  an  acid  fermentation  are  con- 
sumed. The  principal  product  generated  in  these  fruits  and  vegeta- 
bles is  lactic  acid,  and  it  is  due  to  the  presence  of  this  acid  that  putre- 
faction is  prevented." 

In  some  eastern  countries  sour  milk  is  used  to  pickle  meats,  by 
preventing  putrefaction  through  agency  of  its  lactic  acid. 

Sour  milk  may  certainly  be  regarded  as  healthy,  provided  the 
"  souring  "  is  confined  to  the  natural  action  of  the  lactacid  bacteria 
(see  "Koumiss,"  p.  93,  and  "Zoolak,"  p.  95),  and  the  milk  not  con- 
taminated by  streptococci  or  other  common  bacteria  of  dirt.  The 
natural  curdling  which  results  from  souring  is  due  to  precipitation 
of  caseinogen  and  is  different  from  the  coagulation  induced  by 
rennin. 

"  Bacillac "  is  a  sterilized  milk  "  activated "  according  to  Metch- 
nikoff  with  lactic-acid  bacilli,  and  free  from  yeast  and  consequently 
from  alcohol.  It  contains  about  2.5  per  cent  of  lactic  acid. 

"  Lactobacilline "  is  a  preparation  first  made  in  Paris  in  1905 
under  direction  of  Metchnikoff  from  pure  cultures  of  Bacillus  Bul- 
garis,  and  a  second  European  variety  of  bacillus,  consisting  of  com- 
pressed tablets,  one  or  two  of  which  should  be  taken  about  an  hour  and 
a  half  after  meals,  at  the  time  when  they  will  pass  promptly  to  the  in- 
testine with  digested  food.  To  facilitate  their  multiplication  (for 
the  bacilli  are  still  alive)  they  should  be  taken  with  a  lump  of 
sugar  or  a  caramel,  for  they  propagate  best  in  saccharine  media. 
Cohendy  showed  that  an  exclusive  meat  diet  greatly  increased  the 
sulphur  ethers  of  the  urine,  but  when  a  liter  of  milk  soured  by  lacto- 
bacilline  was  added  to  the  daily  proteid  diet  they  almost  entirely 
disappeared,  and  the  lactacid  bacilli  appeared  in  the  feces.  Lactic 
acid  may  be  used  similarly,  but  the  lactacid  bacilli  are  more  power- 
ful, and  do  not  produce  the  gastric  and  renal  irritation  which  the  acid 
is  liable  to  induce. 

The  milk  poured  by  lactobacilline  differs  from  other  soured  milks, 
such  as  Koumiss,  in  the  absence  of  yeasts,  which  cause  in  addition 
alcoholic  fermentation. 


ANIMAL  FOODS  93 

"  Lactone "  is  a  tablet  preparation  of  pure  culture  of  lactacid 
organisms  first  made  also  in  1905  by  Parke,  Davis  &  Co.  at  the  in- 
stigation of  H.  G.  Piffard.  One  of  these  tablets  may  be  added  to  a 
quart  of  fresh  milk  to  sour  it  diluted  with  one-third  hot  water. 
One  or  one  and  a  half  pint  may  be  taken  daily  between  meals. 
Tissier  employs  pure  cultures  of  lactacid  bacteria  grown  in  lactose 
broth,  for  intestinal  disorders. 

Sour  milk  undoubtedly  constitutes  a  wholesome  and  nourishing 
food  for  those  who  can  digest  it,  but  with  invalids  I  often  have  found 
it  to  disagree,  producing  nausea,  vomiting,  and  in  time  "  biliousness." 
There  is  at  present  much  discussion  as  to  its  value  for  infant  feed- 
ing, and  while  there  are  those  who  strongly  advocate  its  exclusive  use, 
others  are  opposed  to  employing  it  at  all.  No  doubt  much  de- 
pends upon  the  care  given  to  its  derivation,  for  it  is  easily  con- 
taminated, especially  in  large  cities.  In  fact,  in  New  York  city  the 
sale  of  sour  milk  is  prohibited  by  the  Health  Department  as  being, 
on  the  whole,  a  safer  measure.  Milk  soured  by  lactobacilline  is  espe- 
cially recommended  by  Metchnikoff  (in  doses  of  one  to  one  and  a 
half  pints  taken  three  times  a  day  with  or  between  meals)  for  all 
diseases  of  the  alimentary  canal  and  kidneys  and  skin  diseases  of 
general  or  constitutional  type.  Metchnikoff's  experiments  have  been 
confirmed  by  Tissier  and  Cohendy. 

3.  Koumiss. —  Koumiss  (spelled  also  koumys  and  kumyss)  is  a  sour 
whole  milk  artificially  prepared  by  simultaneous  lactic  acid  and  alco- 
holic fermentation.  It  was  originally  made  by  the  natives  in  the 
steppes  of  southeastern  Eussia  and  other  eastern  countries  as  a  re- 
freshing and  slightly  intoxicating  beverage.  Of  late  jrears  the  idea 
has  been  advanced  that  it  has  some  beneficial  or  curative  influence  in 
chronic  diseases,  such  as  phthisis,  chronic  bronchitis,  chronic  gastro- 
intestinal catarrh,  and  other  wasting  diseases,  and  as  a  result  the 
manufacture  of  koumiss  has  been  extensively  introduced  into  the 
United  States,  and  at  many  pharmacies  it  may  be  obtained  daily, 
freshly  prepared,  in  pint  or  quart  bottles. 

The  Manufacture  of  Koumiss. —  The  manufacture  of  koumiss  may 
be  conducted  by  several  different  processes.  In  southeastern  Eus- 
sia, especially  in  south  Samara,  the  milk  of  a  certain  breed  of  mares 
is  used,  which  is  particularly  rich  in  milk  sugar  but  poor  in  fat  and 
casein,  and  the  animals  are  fed  upon  grasses  which  contain  this  sugar- 
forming  material  in  abundance. 

Mare's  milk,  as  compared  with  cow's,  contains  much  more  sugar 
(6  per  cent)  and  less  casein  and  fat  (less  than  3  per  cent). 

The  mares  are  light-colored  animals,  unbroken,  and  are  guarded 


94          FOODS  AND  FOOD  PREPARATIONS 

with  greatest  care,  not  being  allowed  dry  food,  such  as  oats  and  hay. 
Pastured  among  mountains  containing  salt  beds,  they  have  access  to 
running  water,  in  which  they  can  bathe  frequently.  They  have  large 
udders  and  abundant  milk  secretion,  which  is  milked  from  four  to 
six  times  daily.  The  best  koumiss  is  made  in  the  early  summer  by 
pouring  fresh  milk  into  smoked  leather  bottles  or  sabas,  to  which 
is  added  a  little  sour  cow's  milk  or  old  dry  koumiss  ferment.  These 
skins  are  kept  at  a  temperature  about  equal  to  the  body  heat  and 
are  frequently  shaken  for  thorough  mixing,  and  fermentation  is 
allowed  to  proceed  for  three  or  four  days. 

In  the  United  States  koumiss  is  manufactured  from  cow's  milk 
by  the  addition  of  some  artificial  ferment.  Such  home-made  koumiss 
may  be  prepared  as  follows : 

Take  2  teaspoonfuls  of  wheat-flour  dough,  2  tablespoonfuls  of 
millet  flour,  1  tablespoonful  of  honey,  1  tablespoonful  of  beer  yeast. 
Mix  into  a  thin  paste  with  milk.  Place  in  a  warm  place  to  ferment. 
When  fermented,  put  into  a  linen  bag  and  hang  in  a  covered  jar  with 
sixteen  pounds  of  fresh  milk.  Let  stand  for  twenty-four  hours,  or 
until  the  milk  becomes  acid,  at  a  temperature  of  86°  to  90°  F.  Skim, 
decant,  agitate  for  an  hour,  bottle  and  cork  tightly,  protecting  the 
corks  with  wire  fastenings.  Keep  in  a  refrigerator.  Absolute 
cleanliness  must  be  insisted  upon  throughout  all  the  various  ma- 
nipulations; otherwise  different  forms  of  fermentation  will  result 
(Stange). 

Properties. —  Koumiss  when  shaken  froths  readily.  It  has,  when 
fresh,  a  slightly  sour  odor,  agreeable  bitter  taste,  and  acid  reaction. 
The  specific  gravity  is  1.018  to  1.029.  During  fermentation  alcohol 
is  developed  from  the  milk  sugar,  which  forms  lactic  acid  and  glu- 
cose, the  latter  making  alcohol  and  carbonic  acid.  The  alcohol  may 
reach  2.5  per  cent,  but  koumiss  made  from  cow's  milk  may  not  con- 
tain above  1  per  cent.  Koumiss  becomes  stronger  in  both  taste  and 
smell  after  keeping  a  day  or  two.  It  is  highly  sensitive  to  tempera- 
ture changes. 

There  are  two  varieties  of  koumiss  prepared  which  differ  in  de- 
gree of  fermentation  and  in  their  exhilarating  and  intoxicating 
properties.  The  lighter  form  contains  less  alcohol  than  the  heavier, 
in  which  fermentation  has  proceeded  further. 

The  following  analysis  by  Stange  illustrates  the  changes  in  com- 
position which  koumiss  undergoes  by  prolonged  fermentation: 


ANIMAL  FOODS 


95 


Table  of  the  Percentage  Composition   of  the  Several  Strengths  of  Koumiss 

(Stange). 


Mare's 
milk. 

KOUMISS—  DURATION  OF  FERMENTATION. 

6  hours. 

18  hours. 

80  hours. 

4  days. 

Carbonic  acid                .  .  . 

3.8 
18.5 
3.9 
18.8 
22.5 
18.9 
4.5 

6.0 
19.5 
5.6 
16.3 
22.6 
20.0 
4.0 

7.0 
30.0 
6.4 

2o!6 

19.0 
4.0 

11.0 
30.0 
6.4 

ie!6 

19.0 
4.0 

Alcohol          

Lactic   acid    

Milk   sugar    

51 
23 
19 
5 

Albumin    

Fat    

Salts    

The  casein,  after  first  being  precipitated,  is  converted  into  pep- 
tones and  an  acid  albumin.  It  should  be  remembered  that  the  com- 
position of  koumiss  is  always  changing  unless  the  fermentation  be 
held  in  check  by  extreme  cold.  Koumiss  grows  more  and  more  acid 
and  keeps  but  a  short  time  when  exposed  to  the  air.  If  spoiled,  it 
may  produce  severe  symptoms  of  ptomaine  poisoning. 

Koumiss  is  prepared  in  tablet  form  under  the  name  of  koumysgen, 
each  tablet,  it  is  claimed,  containing  30  per  cent  of  soluble  casein. 
The  tablets  keep  indefinitely  in  air-tight  bottles,  and  when  dissolved 
in  water  form  a  cooling  effervescing  food,  possessing  similar  proper- 
ties with  koumiss,  and  it  is  cheaper.  It  is  doubtful,  however,  whether 
any  preparation  can  be  made  to  reproduce  all  the  peculiarities  and 
advantages  of  fresh  koumiss,  which  is  so  variable  and  delicate  a 
substance. 

The  "  Koumiss  Cure  "  is  described  under  that  heading. 

Kefir. —  Kefir  is  another  form  of  fermented  milk  which  resembles 
koumiss,  and  has  long  been  used  in  the  Caucasus.  It  contains  three 
varieties  of  ferments  which  produce  complex  fermentation  processes 
resulting  in  the  formation  of  one  per  cent  of  alcohol,  besides  lactic 
acid,  modified  albumins,  and  peptones.  The  casein  of  milk  is  in 
great  part  digested  by  them,  and  the  portion  which  remains  is  pre- 
cipitated in  flocculi  instead  of  heavy  curds.  The  milk  sugar  is  al- 
most completely  converted  into  alcohol  and  carbonic-acid  gas,  which 
bubbles  to  the  surface.  Kefir  has  a  sour  taste,  due  to  the  organic 
acids  which  it  contains.  Hayem  and  Eovighi  have  shown  its  bene- 
ficial effect  is  due  to  the  presence  of  lactic  acid,  rather  than  to  "  pre- 
digestion." 

Zoolak. —  Zoolak,  formerly  called  Matzoon,  is  a  form  of  milk 
previously  sterilized  in  which  lactic-acid  fermentation  has  been  pro- 
duced by  a  ferment  much  used  in  Syria  and  southeastern  Europe. 
The  ferment,  called  by  the  Armenians  "maadzoun,"  contains  the 


96          FOODS  AND  FOOD  PREPARATIONS 

Bacillus  Bulgaris  and  yeast.  Its  acidity  equals  one  per  cent.  Fresh 
zoolak  does  not  effervesce  as  older  preparations  do.  It  has  the  same 
general  properties  and  effects  as  koumiss,  and  is  an  excellent  invalid 
food.  The  trade  name  Matzoon  was  changed  to  Zoolak  by  M.  G. 
Dadirrian,  of  New  York. 

Yohourd  is  a  soft  semi-solid  fermented  preparation  of  milk  fer- 
mented by  a  somewhat  different  process  from  zoolak,  and  sold  in 
Philadelphia  by  the  Eussian  Kefir  Co.  It  contains  lactic-acid  bacilli 
and  yeast. 

Clabberade  is  another  milk  fermented  by  bacilli  and  yeast. 

Leben  raib  is  a  sour  fermented  milk  used  in  Egypt  and  Algeria. 
It  contains  three  species  of  bacteria  and  two  of  yeast. 

Carbonated  Milk. —  According  to  L.  L.  Van  Slyke  and  A.  W. 
Bosworth  of  the  Xew  York  State  Agricultural  Experiment  Station: 

"  Milk  carbonated  under  a  pressure  of  TO  pounds  comes  from  the 
bottle  as  a  foamy  mass,  more  or  less  like  koumiss  that  is  two  or  three 
days  old.  It  has  a  slightly  acid,  pleasant  flavor,  due  to  the  carbon 
dioxid,  and  has  a  somewhat  more  salty  taste  than  ordinary  milk. 

"  The  best  results  were  secured  when  newly  pasteurized  milk  or 
cleanly  drawn  fresh  milk  was  treated  with  carbon  dioxid  in  a  tank, 
such  as  is  used  in  bottling  establishments  in  preparing  carbonated 
drinks,  and  then  placed  in  siphon  bottles.  When  charged  under  pres- 
sures of  from  70  to  75  pounds  and  kept  at  temperatures  ranging  from 
35°  to  60°,  bottles  of  clean  fresh  milk  or  pasteurized  milk  kept  from 
four  to  five  months  without  perceptible  increase  in  acidity." 

IV.  Methods  of  Sterilization,  Pasteurization,  and  Modification. 

1.  Sterilization.  2.  Pasteurization.  3.  "  Humanized  milk."  4. 
Modified  milk.  Milk  laboratories. 

1.  Sterilized  Milk. —  The  sterilization  of  milk  is  accomplished  by 
heating  to  the  boiling  point,  212°  F.  In  a  vacuum  this  may  be 
accomplished  by  a  temperature  a  few  degrees  lower. 

The  construction  of  steam  sterilizers  for  milk,  beef  tea,  or  other 
foods  is  based  upon  a  very  simple  plan.  Bottles  containing  the  food 
to  be  sterilized  are  suspended  in  racks  in  the  upper  part  of  a  tin  or 
copper  vessel  in  an  atmosphere  of  steam,  and  their  contents  soon  ac- 
quires the  temperature  of  boiling  water  (212°  F.),  which  fills  the 
lower  part  of  the  chamber. 

Mobnm  preserves  milk  for  six  months  by  heating  it  in  a  tin  re- 
ceptacle, the  only  opening  of  which  is  through  a  lead  tube.  The 
milk  is  rendered  sterile  by  heat,  and  all  air  is  driven  out  through  the 
tube,  which  is  then  compressed  and  soldered. 


ANIMAL  FOODS  9? 

The  taste  of  sterilized  milk  is  peculiar,  resembling  that  of  boiled 
milk.  If  put  in  bottles  which  have  been  sterilized  by  boiling  water  or 
steam  (Fig.  16),  by  stopping  them  with  pledgets  of  absorbent  cotton 
which  have  been  baked,  the  milk  will 
keep  fresh  for  a  number  of  days  — 
long  enough  to  be  carried  upon  a 
voyage  to  England  or  across  the  con- 
tinent. 

In  1899  sterilizing  apparatus  was 
introduced  at  the  Children's  Hospital, 
Randall's  Island,  New  York  city, 
with  the  immediate  effect  of  reducing 
the  excessive  annual  infant  death  rate 
from  44.36  to  19.86.  If  milk  be  too 
long  sterilized  it  becomes  of  a  brown- 
ish hue,  owing  to  the  conversion  of  its 
lactose  into  caramel.  It  is  not  defi- 
nitely proven  that  prolonged  use  of 
sterilized  milk  causes  scurvy  in  in- 
fants, and  the  disease  may  be  due  to 
other  factors. 

According  to  Leeds,  the  following 
alterations  are  produced  in  milk  by    FIG.  16.— THE  ARNOLD  STERILIZER 
sterilization  at  212°  F.  (Fig.  17)  :     1.  (Holt). 

The  amylolytic  ferment  is  destroyed.  2.  The  casein  is  coagulated  less 
readily  by  rennin.  3.  The  digestibility  of  casein  by  the  gastric  and 
pancreatic  juices  is  somewhat  retarded.  4.  The  fat  is  less  promptly 
absorbed  than  normally  from  the  intestine.  5.  If  the  heating  is  con- 
tinued for  some  time,  the  milk  sugar  is  destroyed. 

The  mineral  salts  of  milk  are  also  dissociated  in  some  degree  from 
their  organic  compounds. 

It  is  thus  demonstrated  that  the  chief  change  produced  by  steril- 
ization of  milk,  and  even  by  pasteurization  at  167°  F.,  is  destruction 
of  the  enzymes  or  organic  ferments  of  which  this  highly  complex 
fluid  contains  a  number.  Babcock  and  Russell  of  Wisconsin  have 
shown  that  when  milk  is  rendered  aseptic  by  salicylic  acid,  sodium 
fluoride  or  other  germicides,  a  process  of  self-digestion  goes  on, 
which  increases  the  longer  the  milk  is  kept.  The  result  of  this 
natural  process  is  the  formation  of  albumoses  at  the  expense  of 
casein,  and  the  action  is  due  to  a  ferment  which  these  experimenters 
named  "  galactase,"  resembling  trypsin. 

Another  ferment,  an  oxydase  or  anaeroxydase,  has  been  demon- 


98 


FOODS  AND  FOOD  PREPARATIONS 


strated  in  cow's  milk  by  a  number  of  French  experimenters.  This 
ferment,  as  its  name  implies,  causes  a  peculiar  reaction  in  milk  to- 
wards oxidizing  agents,  such  as  turpentine  or  tincture  of  guaiac. 

Spolverini  identified  a  new  ferment  in  cow's  milk  which  resem- 
bles closely  the  glycolytic  ferment  of  the  blood. 

A  ferment,  called  by  Bourquelot  "lipase,"  has  been  identified  in 
both  human  and  cow's  milk;  its  action  is  hydrolytic,  resolving  mono- 
butyrin  into  glycerin  and  butyric  acid. 


FIG.   17. —  STERILIZATION  OVEN  USED  IN  BOTTLING  MILK  UNDEB  STEAM 

PRESSURE. 
(E.    H.    Webster,    Bui.    41,    Hygienic   Laboratory.) 

In  churning  sterilized  milk,  butter  forms  more  slowly  than  from 
raw  milk,  a  period  two  or  three  times  longer  being  required.  Hirsch 
attributes  this  to  toughening  of  the  albuminoid  envelopes  (of  lactal- 
bumin)  of  the  fat  globules,  which  is  produced  by  the  heat. 

Owing  to  the  complicated  changes  which  sterilized  milk  undergoes, 
an  infant  to  be  fully  nourished  on  it  requires  more  of  it  than  of  raw 
milk. 

Practically,  in  normal  stomachs  of  either  infants  or  adults  these 
changes  arc  not  sufficiently  pronounced  to  interfere  seriously  with 
the  digestibility  of  the  milk,  but  dyspeptic  and  catarrhal  conditions 
of  the  stomach,  especially  in  infants,  make  it  highly  sensitive  to  very 
slight  modifications  in  the  composition  and  reaction  of  milk. 


ANIMAL  FOODS  99 

In  quite  recent  years  it  has  been  proved  that  the  method  of  pas- 
teurization is  preferable  to  sterilization  (see  Pasteurized  Milk, 
p.  100,  but  there  is  a  decided  reaction  against  the  prolonged  use  of 
both  these  types  of  milk,  in  distinction  from  temporary  emergency 
use,  and  von  Behring  in  common  with  many  American  clinicians 
maintains  that  when  mother's  milk  is  unprocurable,  the  proper  infant 
food  is  good,  fresh,  clean  milk,  not  heated  or  otherwise  modified  by 
necessary  dilution  or  sweetening.  Von  Behring  states  that  fresh  milk 
contains  powerful  antibodies  which  react  against  the  Bacillus  aci'di 
lactici  and  colon  bacillus.  As  these  are  the  two  types  of  bacilli  com- 
monly present  in  the  infant  organism,  and  as  the  heat  of  steriliza- 
tion or  pasteurization  promptly  destroys  the  antibodies,  by  the  use 
of  heated  milk  the  infant  is  deprived  of  a  protective  agent  against 
gastrointestinal  disorder. 

After  all,  in  selecting  a  proper  milk  for  infant  feeding,  the 
question  of  immediate  digestibility  is  bound  up  in  that  of  permanent 
effect  upon  nutrition.  The  difficulty  with  infant  feeding  among 
the  poor  is  to  obtain  really  good,  fresh,  raw  milk;  hence  in  a  given 
case  the  choice  of  feeding  must  ultimately  depend  upon  the  character 
of  raw  milk  obtainable.  When  this  is  first-class  the  relative  digesti- 
bility, as  well  as  relative  permanent  nutritive  value,  stands  as  follows 
in  order  of  preference :  (1)  raw,  (2)  pasteurized,  (3)  sterilized. 

The  directions  for  predigestion  combined  with  sterilization  of  milk 
at  the  Philadelphia  Hospital  are  thus  given  by  Hirst : 

"  1.  Have  the  nursing  bottles  prepared  clean  every  morning. 

"  2.  Take  cream,  five  ounces ;  milk,  two  and  a  half  ounces. 

"  3.  Put  in  skillet ;  add  pancreatin  powder  (pancreatin,  two  and  a 
half  grains;  sodium  bicarbonate,  five  grains) ;  heat  over  alcohol  flame 
for  six  minutes ;  stir  and  sip  constantly ;  do  not  overheat. 

"  4.  Of  this  mixture  put  in  each  bottle  six  drachms  (for  a  two- 
ounce  bottle).  Use  funnel. 

"  5.  Add  to  each  bottle  ten  drachms  of  sugar  solution.  (Make 
sugar  solution  by  dissolving  an  ounce  of  sugar  of  milk  (one  powder) 
in  a  pint  of  warm  water.) 

"  6.  Stopper  the  mouth  of  each  bottle  with  dry  baked  cotton  and 
sterilize  for  twenty  minutes. 

"  7.  Set  aside  to  cool. 

"  8.  Before  use  put  bottle  in  warming  cup ;  apply  nipple  imme- 
diately before  giving  to  infant." 

The  alimentary  canal  of  the  newborn  infant  is  sterile  —  it  con- 
tains no  bacteria  —  but  after  the  first  few  passages  of  meconium  two 
species  of  bacilli  and  one  of  micrococci  are  found  (Escherich,  Bes- 


100          FOODS  AND  FOOD  PREPARATIONS 

lau),  which  disappear  with  the  meconium.  There  are  only  two  species 
of  bacteria  found  in  the  stools  of  healthy  nursing  infants,  the  Bac- 
terium lactis  aerogenes,  obtained  from  the  ileum  below  the  duodenum, 
and  Bacillus  coli  communis,  from  the  colon. 

In  diarrhoeal  conditions  other  bacteria,  to  the  number  of  forty 
species,  have  been  found  (Booker).  Their  action  in  different  dis- 
eases is  not  yet  differentiated,  but  they  are  associated  more  or  less 
directly  with  malfermentation  and  the  formation  within  the  intes- 
tines of  gases  and  irritating  or  poisonous  products.  Many  of  these 
species  thrive  and  are  reproduced  in  hot  weather  outside  the  body 
in  milk,  in  the  atmosphere,  and  upon  diapers  and  utensils.  This 
explains  the  importance  of  absolute  aseptic  cleanliness  in  every- 
thing that  pertains  to  the  nursing  and  feeding  of  infants  —  cleanliness 
of  the  breasts  and  nipples,  of  the  nurse's  hands,  of  all  receptacles  for 
milk  or  other  foods,  of  the  child's  body,  and  prompt  removal  and 
disinfection  of  soiled  diapers  or  clothing. 

The  most  important  fact  in  regard  to  both  sterilized  and  pas- 
teurized milk  is  that  these  processes,  while  they  kill  all  the  germs 
already  contained  in  milk,  do  not  prevent  its  immediate  reinfection 
when  exposed  to  any  of  the  common  sources  of  contamination.  In 
fact,  as  Eotch  says,  "  form  a  cloak  of  dirt." 

2.  Pasteurized  Milk. —  Pasteurized  milk  is  similarly  prepared  to 
sterilized  milk,  and  is,  in  fact,  sterile,  but  the  temperature  is  only 
raised  for  twenty  minutes  to  167°  F.,  instead  of  the  boiling  point, 
212°  F.  It  is  not  certain  that  it  is  any  more  digestible  than  un- 
heated  milk. 

It  does  not  keep  so  long  as  sterilized  milk  and  spoils  in  one  or  two 
days,  but  it  has  the  advantage  of  tasting  more  like  fresh  milk. 

Cleansing  Milk  Bottles. — Both  sterilized  and  pasteurized  milk 
should  be  warmed  by  placing  the  milk  bottles  in  warm  water  without 
opening  them.  If  the  bottles  are  to  be  used  again  they  should  be 
rinsed  and  left  standing  full  of  water  to  which  one  or  two  teaspoon- 
fuls  of  borax  or  soda  have  been  added.  Before  filling  with  milk 
they  should  be  washed  with  a  fresh  swab  and  hot  soapsuds,  rinsed 
again  with  boiled  water,  and  kept  for  at  least  twenty  minutes  in  boil- 
ing water,  or  they  may  be  placed  in  a  steam  sterilizing  apparatus 
under  pressure.  Eubber  nipples  for  infants'  bottles  should  be  kept  in 
borax  water  and  rinsed  several  times  daily.  Eubber  tubing  should 
be  discarded. 

The  thermal  death  point  of  disease  germs  in  milk  has  been  estab- 
lished by  M.  J.  Kosenau  (U.  S.  Hygienic  Laboratory  Bui.  42,  1908) 
as  follows :  Bacillus  tuberculosis  140°  F.  for  20  minutes,  or  in 


ANIMAL  FOODS 


101 


less  time  at  149°  F.,  B.  diptherice  and  cholera  bacillus,  131°  P.;  J9.  dys- 
entercw,  140°  F.  for  10  minutes.  Practically  twenty  minutes'  exposure 
to  140°  F.  kills  all  harmful  germs  in  milk,  including  the  Streptococcus 
pyogenes,  the  Staphylococcus  pyogenes  aureus,  and  the  Bacillus  coli- 
communis.  There  are  a  few  exceptions,  however,  among  spore  forms. 

The  Bacillus  acidi  lactici  is  also  prevented  from  acting  after  ex- 
posure to  a  temperature  of  160°  F. 

It  is  found  that  by  immersing  bottles  of  milk  in  water  which  has 
just  been  removed,  while  boiling,  from  the  fire,  a  fairly  uniform 


FIG.    18. —  A   MODERN   HIGH-CLASS    PASTEXJBIZING    PLANT. 
(E.   H.   Webster,   Bui.   41,   Hygienic   Laboratory.) 

temperature  of  167°  F.  is  obtained.  Naturally,  the  relation  between 
the  volume  of  water  used  and  the  quantity  of  milk  should  be  balanced 
properly,  and  various  forms  of  graduated  receptacles  are  sold  which 
make  the  process  very  simple. 

A  graduated  covered  pail,  into  which  the  boiling  water  is  poured, 
is  fitted  with  a  rack  to  submerge  enough  bottles  of  milk  for  the  day's 
use,  and  this  is  all  that  is  necessary.  After  half  an  hour's  exposure 
to  the  heat  the  milk,  as  in  the  case  of  sterilized  or  pancreatinized 
milk,  is  set  in  a  refrigerator  until  ready  for  use. 


102 


FOODS  AND  FOOD  PREPARATIONS 


Under  some  conditions  both  sterilized  and  pasteurized  milk  form 
smaller  curds  than  raw  milk,  although  this  is  not  the  case  with  the 
coagulae  formed  by  gastric  juice  (Freeman). 

The  poor  in  New  York  city  are  now  supplied  with  cheap  pasteur- 
ized milk  through  the  philanthropy  of  Mr.  Nathan  Straus,  who  in 
1893  opened  the  first  milk  depot  for  dispensing  pure  milk  and  pas- 
teurized milk,  at  a  cost  of  but  one  and  a  half  cent  for  an  eight-ounce 
bottle.  A  sterilized  nipple  is  also  furnished  with  each  bottle.  The 


FIG.   19.^ —  FREEMAN'S  PASTEURIZER. 
Aj  Bottles  in  position  for  heating;  B,  Method  of  cooling  (Holt). 

bottles  have  sloping  necks,  to  facilitate  cleansing,  and  spheroidal  bot 
toms  to  prevent  them  from  being  left  standing  about  uncorked  (Fig. 
19).  In  an  account  of  this  system  Dr.  Freeman  states  that: 

"  In  addition  to  pasteurized  ordinary  milk  and  pasteurized  modi- 
fied milk,  a  pasteurized  milk  diluted  with  barley  water  and  sweet- 
ened with  cane  sugar,  and  containing  also  table  salt,  has  been  intro- 
duced at  the  suggestion  of  Dr.  A.  Jacobi.  The  formula  used  is : 

Table   salt    %  oz. 

White  cane  sugar    10  oz. 

Milk    1  gal. 

Water    1  gal. 

"  This  barley  milk  will  be  dispensed  in  six-ounce  bottles." 
There  has  been  much  recent  discussion  as  to  the  effect  of  continued 
use  of  pasteurized  milk  as  a  food.  The  process  destroys  certain 
natural  milk  ferments  that  aid  its  digestibility,  as  well  as  certain 
properties  of  fresh  milk  which  render  it  resistant  to  bacterial  growth. 
The  acidity  of  milk  is  tested  by  Health  Boards  as  a  measure  of  its 
purity,  owing  to  the  parallelism  between  the  degree  of  acidity  and 
number  of  bacilli  present,  but  pasteurization  interferes  with  this  test. 
Thus  Berger  found  148,000,000  bacteria  per  c.c.  in  a  specimen  of 


ANIMAL  FOODS  103 

pasteurized  milk  that  was  not  acid  enough  to  be  condemned.  Certain 
spore  forms,  mainly  of  the  B.  subtilis  group,  survive  pasteurization. 

3.  Humanized  Milk. —  Humanized  milk  is  really  Pasteurized  milk 
with  a  permanent  alkaline  reaction  and  partial  predigestion.     Leeds 
claims  the  credit  for  the  origin  of  the  idea  of  this  form  of  milk,  and 
his  formula  is: 

Milk    %  pint. 

Water %     " 

Cream    4  tablespoonfuls. 

Peptogenic  milk  powder   1  large  measure. 

Heat  to  160°  to  170°  F.  for  ten  to  twenty  minutes. 

Instead  of  cream,  some  other  form  of  fat  may  be  added  for  invalids, 
such  as  olive-oil,  cod-liver  oil  or  cacao  butter. 

The  name  "  humanized  milk "  is  applied  somewhat  indefinitely 
to  various  preparations  of  cow's  milk  in  which  the  attempt  is  made 
to  approach  more  nearly  the  composition  of  human  milk  by  lessen- 
ing the  casein  and  increasing  the  sugar  and  fat.  These  prepara- 
tions are  partially  predigested,  but  the  pancreatinization  is  stopped 
before  it  has  proceeded  far,  so  that  the  infant  stomach  shall  still 
have  some  work  to  do. 

Another  good  mixture  designed  to  resemble  human  milk  is  that 
of  Meigs : 

Cream    2  tablespoonfuls. 

Milk     1  tablespoonful. 

Lime  water    2  tablespoonfuls. 

Water    3 

Milk   sugar    %  teaspoonful. 

4.  Modified  Milk.     Milk  Laboratories. —  The  establishment  of  milk 
laboratories  having  in  view  the  object  of  modifying  cow's  milk  for 
infant  and  invalid  feeding  has  demonstrated  the  practical  value  of 
this  work.     Such  milk  is  now  called  "  modified  milk,"  and  the  process 
consists  in  separating  the  chief  components  of  cow's  milk  and  re- 
combining  them  to  resemble  their  proportions  in  human  milk. 

Feeding  infants  with  this  milk  is  spoken  of  as  "  percentage  feed- 
ing," and  e.  g.,  such  a  formula  as  4,  7,  2  refers  to  the  percent- 
age of  fat  (4),  sugar  (7),  proteid  (2).  The  first  laboratory  founded 
in  Boston  during  1892-'93,  upon  the  suggestions  of  Dr.  Eotch,  com- 
pletely fed  about  twelve  hundred  infants  and  was  patronized  by  more 
than  one  hundred  and  fifty  physicians  in  its  first  year.  Many  similar 
laboratories  subsequently  have  been  established.  The  milk  is  derived 
from  carefully  selected  animals  kept  at  farms  where  their  food,  sta- 


104          FOODS  AND  FOOD  PREPARATIONS 

bling,  drinking  water,  and  pasture  are  under  the  scientific  supervision 
of  a  veterinary  surgeon. 

It  is  possible  to  avoid  all  variation  in  milk  and  keep  it  at  a  stand- 
ard which  may  be  graded  to  correspond  with  the  increasing  age  of  the 
infant,  by  the  employment  of  proper  means  in  the  milk  laboratories, 
where  milk  may  be  prepared  with  its  ingredients  mixed  with  the 
accuracy  of  a  medicinal  prescription,  while  its  freshness  and  purity 
are  absolutely  insured.  If  desired  also,  the  milk  may  be  predigested 
in  the  laboratory,  and  sweet  whey  and  other  materials  derived  from 
fresh  milk  may  be  obtained  there. 

Physicians  are  furnished  with  blank  forms  upon  which  they  may 
prescribe  definitely  the  composition  of  the  milk  which  they  wish  to 
order  for  any  individual  case.  A  sample  prescription  form  from  the 
Briarcliff  Laboratory  is  herewith  appended: 


Per  cent. 

Remarks. 

Fat 
Milk   sugar 
Proteids 
Mineral  matter 

Number  of 
feedings  ? 

Amount  at 
each  feeding? 

Infant's  age? 
Infant's  weight? 

Total   solids 
Water 

100.00 

Alkalinity. 

Raw.     Pasteurised  °  F.         Sterilised  °  F. 

Ordered   for 

Date  Signature 

M.  D. 


"  If  the  physician  does  not  care  to  mention  the  especial  per- 
centage, he  can  ask  for  percentages  which  will  correspond  to  the 
analysis  of  human  milk,  and  he  can  then  vary  any  or  all  of  these 
percentages  later,  according  to  the  need  of  the  especial  infant  pre- 
scribed for"  (Eotch). 

In  order  to  prepare  modified  milk  by  Eotch's  method  it  is  neces- 
sary to  have:  1.  Pure  cream  containing  the  fat.  2.  Pure  milk  con- 
taining the  albuminoids  and  no  fat.  3.  Distilled  water.  4.  A  20- 
per-cent  solution  of  milk  sugar  made  fresh  daily  with  distilled  water. 
5.  Lime  water. 

The  milk  and  cream  are  separated  by  an  apparatus  (Fig.  20,  p.  110) 
made  to  revolve  6.SOO  times  per  minute,  so  that  they  may  be  recom- 
bined  in  any  desired  proportion.  The  resulting  cream  has  an  aver- 


ANIMAL  FOODS  105 

age  of  35  per  cent  of  fat,  but  the  percentage  may  vary  between  45  and 
18,  hence  analysis  should  be  made  whenever  accuracy  is  essential. 
After  separation  of  the  cream  the  milk  is  modified  according  to  the 
formula  prescribed  for  each  case,  and  pasteurized. 

Kotch  gives  the  following  sample  prescriptions  for  modified  milk 
to  be  sent  by  the  physician  to  the  laboratory : 

I£    (1)    A  girl  6  years  old:   duodenal  jaundice. 

Fat  0.50 

Milk  sugar  6.00 

Albuminoids  4.00 

Give  4  ounces  every  two  hours. 

Send  12  tubes,  each  4  ounces;  lime  water, -j^. 

NOTE. —  This  patient  made  a  rapid  recovery.     No  medicines  were  given. 

]£    (2)   A  boy  6  weeks  old:   healthy. 

Fat  3.00 

Milk  sugar  7.00 

Albuminoids  1.50 

Send  12  tubes,  each  2  ounces. 

Lime  water,  ^. 

Pasteurise  at  167°  F. 

Jfr    (3)   A  boy   6  months  old:    healthy. 

Fat    4.00 

Milk  sugar   7.00 

Albuminoids 2.00 

Send  8  tubes,  each  6  ounces. 
Lime  water,  ^ 
Pasteurise  at  167°  F. 

I£    (4)   A  girl  4  months  old:   albuminoid  digestion  weak. 

Fat  4.00 

Milk  sugar  7.00 

Albuminoids  0.75 

Send  8  tubes,  each  4  ounces. 

Lime  water,  •£$. 

Pasteurise  at  167°  F. 

]£    (5)    A  boy  6  months  old:  sugar  digestion  weak. 

Fat  3.00 

Milk  sugar  4.00 

Albuminoids  2.00 

Send  8  tubes,  each  6  ounces. 

Lime  water,  ^ . 

Pasteurise  at  167°  F. 

I£    (6)    A  girl  4  months  old:  summer  diarrhoea.     Food  has  to  be  sent  out  of 
town  by  express. 

Fat    2.00 

Milk  sugar 5.00 

Albuminoids    1.00 

Send  20  tubes,  each  1  ounce  and  1  drachm. 

At  time  of  each  feeding  add  lime  water,  3  drachms. 

Sterilise  at  212<°  F. 

NOTE. —  In  this  case  the  diarrhoea  had  not  been  sufficiently  studied  to  deter- 
mine whether  it  was  putrefactive  or  fermentative,  so  that  a  safe  general 
prescription  was  sent  to  begin  with.  The  lime  water  had  to  be  introduced  at 
each  feeding  on  account  of  the  212°  F.  sterilisation  necessitated  by  the  hot 
weather  and  the  distance  to  be  sent. 
10 


106 


FOODS  AND  FOOD  PREPARATIONS 


An  ingenious  measuring  glass  is  recommended  by  L.  Emmet  Holt 
for  the  home  modifying  of  milk.  The  glass,  which  is  sold  under  the 
name  of  the  "  Materna "  (Estraus),  holds  sixteen  ounces  and  has 
seven  paneled  sides.  On  one  side  is  graduated  the  quantity  of 
separate  ingredients  of  normal  milk  and  on  each  of  the  other 
panels  is  graduated  the  ratio  of  ingredients  of  milk  modified  to 
suit  a  certain  age  of  infancy.  Milk  sugar  is  placed  in  the  bottom 
of  the  glass,  water  is  added  to  a  marked  level,  then,  in  turn,  lime 
water,  cream,  and  milk.  The  formulas  given  are  the  following 
(Holt)  : 


FORMULA. 

1. 

2. 

3. 

4. 

5. 

6. 

Fat 

Sugar 
Proteids. 

11 

0.6% 

v&% 

6    % 
0.8% 

3% 
6% 
1% 

n 

1M% 

4% 
*& 

For  this  Formula 
6  see  special 
instructions 
below. 

8M% 

V:'r 
*%% 

Milk         parts 
Cream             " 
Lime  water    " 
Water 
Milk  sugar  " 

3d  day  to  2dwk.to 
14th  dav.  6th  wk. 

6th  wk.  to 
llth  wk. 

llth  wk. 
to  5th  mo. 

5th  mo.  to 
9th  month 

9th  mo.  to 
12th  mo. 

P 
•? 

i| 

3* 

11, 

2 
2 

i 

!> 

t 

6 
2 

1 

11 

Milk        parts 
Cream 
Barley  gruel  " 
Gran,  sugar   " 

? 

Holt  gives  the  following  convenient  formula  for  modifying  cow's 
milk: 

Starting  with  milk  sugar,  one  ounce;  lime  water,  one  ounce,  and  water 
enough  to  make  twenty  ounces,  add  from  time  to  time  respectively  2,  3,  4,  5, 
and  6  ounces  of  10  per  cent,  milk,  giving  the  following  percentages:  fat  1, 
sugar  5.5,  proteids  0.33;  fat  1.5,  sugar  5.5,  proteids  0.5;  fat  2.,  sugar  6., 
proteids  0.6;  fat  2.5,  sugar  6,  proteids  0.8;  fat  3,  sugar  6,  proteids  1. 

According  to  Eotch,  "  certain  breeds  of  cows  are  better  than  others 
for  copying  human  milks." 

List  of  Breeds  best  Adapted  for  Modified  Milk,  with  Analyses    (Eotch). 


Fat. 

Milk 
sugar. 

Albumi- 
noids. 

Mineral 
matter. 

Total 
solids. 

Water. 

Durham    

Percent. 

4.04 

Percent. 

4.34 

Percent. 
4.17 

Percent. 

0.73 

Percent. 
13.28 

Percent. 

86.72 

Devon   

4.09 

4.32 

4.04 

0.76 

13.21 

86.79 

Avrshire       

3.89 

4.41 

.  4.01 

0.73 

13.04 

86.96 

Holstein-Friesian    
American    grades     .... 
Common    natives    

2.88 
4.01 
3.69 

4.33 
4.36 
4.35 

3.99 
4.06 
4.09 

0.74 
0.74 
0.73 

11.94 
13.17 
12.86 

88.06 
86.83 
87.14 

The  Jersey  cow  may  yield  more  than  6  per  cent  of  fat. 

"  The  time  of  the  year,  the  food  and  care  given  to  the  cattle,  the 


ANIMAL   FOODS 


107 


month  of  lactation,  and  manner  of  milking  —  all  exert  such  a  profound 
influence,  that  the  fat  may  be  lower  than  2.5  per  cent  or  as  high  as 
8  per  cent"  (Major  C.  E.  Woodruff,  TJ.  S.  A.). 

Milk  Foods. —  Many  so-called  "  milk  foods  "  are  sold  for  infant 
and  invalid  use.  Their  object  is  to  furnish  a  ready-made  substitute 
for  fresh  milk,  which  is  easy  of  preparation  even  by  an  unintelligent 
nurse.  Generally  speaking,  the  continued  use  of  such  foods,  espe- 
cially for  young  growing  infants,  is  to  be  condemned  whenever  fresh 
milk  is  obtainable,  but  in  traveling  at  sea,  or  wherever  good  milk  is 
not  procurable,  and  in  other  emergencies,  they  may  be  resorted 
to  with  advantage,  until  more  favorable  conditions  obtain.  Approxi- 
mate analyses  of  some  of  the  best  known  of  these  foods  are 
appended  below,  and  compared  with  the  composition  of  mother's 
milk. 


NAME  OF  I^OOD 

Analysed 
by. 

Wa- 
ter. 

Sugar. 

Dex- 
trin. 

Starch. 

Fat 

23.39 

6.78 
5.37 
2.96 
12.35 
1.82 
8.30 
1.91 

Albu- 
mi- 
noids. 

Ash. 

Solubility 
in  water. 

Ideal  mother's  milk... 

4  00 

46  78 

23.39 

22.26 
18.00 
10.75 
14.51 
18.48 
16.88 
8  23 

2.44 

3.90 
1.59 
3.02 
8.66 
2.77 
3.13 
1.59 

Very    solu- 
ble. 

Insoluble. 

Malted  milk  

Rach. 

Leeds. 
Stutzer. 

3.27 
4.51 
5.93 
5.80 
7.80 
2.18 
4.72 
3.42 
7.76 
5.17 
6.52 

46.63 
37.47 
30.12 
63.38 
28.66 
50.40 
38.95 
27.08 
29.65 
28.11 
25.52 

17.16 
4.84 
9.14 

Nestle's  milk  food  
Carnrick's  soluble  food 
Lacto-preparata  

83.22 

38.08 

Lactated  food  

10.33 
16.09 

85.17 
5.57 
40.10 

Malted  milk  

Nestle's  milk  food  
Carnrick's  soluble  food 
Lactated  food  

"9".  35 

37.37 
36.43 
41.50 
52  92 

7.45 
1.64 
5.53 
2  19 

10.25 
11.85 
16.69 
9  05 

4.42 
2.61 
3.00 
2  26 

Soluble. 

Carnrick's  soluble  food 
Lactated  food  

Soluble. 

Lacto-preparata  is  a  preparation  of  pure  selected  milk  from  which 
the  cream  has  been  removed  by  centrifugal  force,  and  for  it  is  sub- 
stituted cacao  butter,  which  keeps  better  and  is  quite  nutritious. 
Lime  water  is  then  added  and  the  mixture  is  sterilized,  evaporated, 
powdered,  and  sealed  hermetically  in  cans. 

The  other  foods  of  the  list  above  given  all  contain  considerable 
starch,  and  will  therefore  be  described  in  the  section  upon  Prepared 
Farinaceous  Foods.  (P.  173.) 

Gustav  Gaertner's  Mother  Milk,  according  to  Theodore  Escherich, 
contains  in  percentages,  albumin,  1.76;  cream,  3.0  to  3.5;  lactose, 
2.5 ;  ash,  0.35,  thus  closely  approximating  the  composition  of  human 
milk,  except  that  it  has  less  sugar.  The  fresh  cow's  milk  is  mixed 
with  sterilized  water  and  placed  in  a  centrifugal  separator  to  re- 
move impurities  and  separate  the  superfluous  casein,  without  remov- 
ing the  fat,  to  form  proportions  more  closely  resembling  those  of 
human  milk.  The  casein  curds  of  this  prepared  milk  are  much  more 
some  of  the  energy  may  be  permanently  stored  within  the  body,  and 


108          FOODS  AND  FOOD  PREPARATIONS 

flocculent  than  those  of  the  original  cow's  milk.  By  this  process  the 
milk  also  loses  a  half  of  the  original  salts  and  sugar,  but  the  latter  is 
easily  added  again  when  desired.  The  milk  is  sealed  hermetically 
in  tin  cans,  in  which  it  keeps  fresh  for  a  year  or  two. 

MILK  DERIVATIVES 

The  principal  foods  derived  from  milk  which  are  in  common  use 
are: 

1.  Condensed  milk.  2.  Cream.  3.  Butter.  4.  Buttermilk.  5. 
Cheese.  6.  Whey. 

1.  Condensed  Milk. —  Condensed  milk  is  prepared  by  slowly  evap- 
orating the  water  of  milk  by  moderate  heat  in  vacua  to  the  consistence 
of  honey.  The  first  process  was  patented  by  Martin  de  Lignac  in 
1847,  who  added  cane  sugar  to  the  milk  and  in  the  United  States  it 
was  patented  by  Gail  Borden  in  1856.  In  1879,  Nageli  of  Munich 
first  manufactured  unsweetened  condensed  milk.  As  commonly  made 
at  present,  there  are  two  varieties :  the  "  plain,"  in  which  the  water 
is  evaporated  to  about  59  per  cent,  and  to  which  little  or  no  sugar 
is  added;  a  stronger  sort,  with  which  cane  sugar  is  mixed  in  excess, 
the  water  being  evaporated  to  25  per  cent.  Such  milk  yields  from 
33  to  50  per  cent  of  sugar  among  its  solid  ingredients,  but  some- 
times more  is  added.  A  good  deal  of  the  Swiss  condensed  milk  sold 
in  market,  as  well  as  that  made  in  this  country,  contains  40  per  cent 
of  sugar.  Condensed  milk  should  also  contain  10  per  cent  or  more 
of  butter  fat. 

The  sugar  prevents  fermentation  and  decomposition,  and  when 
condensed  milk  is  put  up  while  hot  in  hermetically  sealed  tin  cans  it 
will  keep  fresh  for  years.  It  will  remain  fresh  for  several  days 
after  a  can  is  opened.  It  is  soluble  in  water  added  to  any  degree  of 
dilution.  Condensed  milk  is  largely  used  for  the  nourishment  of 
infants,  especially  among  the  poorer  classes.  They  thrive  upon  it 
for  a  time,  occasionally  even  better  than  on  raw  milk,  and  it  makes 
them  fat,  owing  to  the  excess  of  sugar  which  it  contains.  It  does  not 
constipate,  and  may  be  slightly  laxative.  But  although  such 
babies  may  appear  robust,  their  flesh  is  not  firm,  they  develop  poorly, 
are  unable  to  resist  disease,  and  may  become  rhachitic. 

Condensed  milk  should  be  diluted  ten  times  for  a  child  a  month 
or  two  old.  and  cream  should  be  added  in  liberal  proportion. 

The  formula  recommended  by  Starr  is: 

Condensed  milk    3  j  5 

Cream     f^  ss. ; 

Hot  water   f^  ijss. 


ANIMAL  FOODS  109 

This  milk,  when  diluted,  speedily  undergoes  lactic  acid  fermenta- 
tion and  causes  diarrhoea  and  thrush. 

Condensed  milk  is  serviceable  on  long  voyages  and  expedi- 
tions where  fresh  milk  cannot  be  obtained  for  use  with  tea,  coffee, 
etc. 

Unsweetened  canned  condensed  milk  made  of  fresh  Swiss  Alpine 
milk,  and  sold  under  various  brands  in  this  country,  is  prepared  by 
evaporation  by  heat  sufficiently  strong  to  render  the  milk  sterile,  so 
that  no  preservative  materials  are  added.  The  water  is  reduced  from 
the  normal  standard  of  88  per  cent  to  about  61  per  cent.  It  is  open 
to  the  same  objections  as  the  use  of  sterilized  milk  (see  Sterilized 
Milk,  p.  96),  but  it  is  better  for  infants  than  those  forms  of  condensed 
milk  in  which  preservation  is  secured  by  the  addition  of  too  large  a 
proportion  of  cane  sugar.  An  analysis  of  one  brand  of  this  milk 
is  given  by  Professor  Goodfellow,  as  follows: 

Water   61.3 

Casein 9.1 

Albumin 1.5 

Fat    11.7 

Lactose     14.3 

Salts    (mineral  matter)    2.1 


100.0 

Milk  may  be  preserved  for  some  time  in  hermetically  sealed  cans 
or  bottles  without  previous  condensation,  but  a  separation  of  the 
cream  eventually  takes  place,  and  butter  forms  in  the  can. 

2.  Cream. —  Cream  is  the  fat  of  milk,  which,  by  virtue  of  its  light 
specific  gravity,  floats  to  the  top  of  vessels  in  which  milk  is  allowed 
to  stand  for  some  hours.  The  globules  collect  in  a  yellow  layer  of 
varying  thickness.  The  rise  of  the  cream  is  retarded  by  coagula- 
tion, but  favored  by  a  cool  temperature  and  by  richness  of  the  milk. 
The  fatty  material  is  complex,  and  consists  of  glycerides  of  stearic, 
palmitic,  myristic,  oleic,  butyric,  and  soluble  fatty  acids.  Churning 
the  milk  causes  the  globules  of  fat  to  coalesce  in  small  lumps  and 
form  butter.  It  is  a  popular  fallacy  that  a  little  warm  water  added 
to  milk  increases  the  cream  formation.  It  lessens  the  specific  gravity 
of  the  milk  and  hastens  the  floating  of  the  globules,  but  the  ul- 
timate quantity  of  cream  is  not  affected.  If  the  cream  falls  below 
5  per  cent  of  the  volume  of  milk,  the  milk  has  been  watered.  The 
normal  average  quantity  of  cream  is  over  8  or  9  per  cent,  but 
there  may  be  above  20  per  cent.  The  breed,  age,  and  feed  of  the 
cow  have  marked  influence  upon  the  quantity  of  cream.  Alderney 
milk  is  rich  in  cream ;  Longhorns  give  proportionately  more  casein. 


110 


FOODS  AND  FOOD  PREPARATIONS 


The  milk  which  comes  from  the  cow  towards  the  end  of  milking 
contains  more  cream  than  that  which  is  first  drawn.  This  fact  should 
be  borne  in  mind  by  those  who  use  milk  drawn  direct  from  the  cow 
into  separate  small  vessels.  Afternoon  milk  is  richer  than  morning 
milk  in  both  protein  and  fat. 

Centrifugal  or  Separator  Cream. —  Cream  may  be  separated  from 
milk  by  centrifugal  force.  A  small  and  large  drum  are  placed  one 


FIG.  20. —  CENTRIFUGAL  MACHINE. 

The  milk  is  poured  into  the  square  can  at  the  top, 
whence  it  flows  into  the  inner  porous  cylinder. 
One  of  the  round  cans  receives  the  milk,  the  other 
the  cream,  and  the  cylinder  is  rotated  by  the  hand 
crank. 


within  the  other,  leaving  a  space  of  a  few  inches  between.  The 
inner  drum  is  made  of  porous  material.  (Fig.  21,  d.)  It  is  filled  with 
milk  and  set  in  rapid  revolution.  The  lighter  cream  remains  in  the 
inner  drum,  while  the  other  ingredients  are  thrown  with  such  violence 
against  the  porous  wall  that  they  are  forced  through  it  into  the  outer 
drum.  (Fig.  21.  c.)  Tt  is  claimed  that  the  cream  is  more  thoroughly 
separated  in  this  manner  than  when  it  is  allowed  to  rise  on  standing, 


Ill 


and  the  process  is  far  more  rapid.  Separator  cream  does  not  remain 
fresh  so  long  as  that  obtained  by  natural  means,  for  it  is  separated  at  a 
temperature  favorable  to  the  growth  of  bacteria.  Separator  cream 
contains  from  15  to  50  per  cent  of  fat,  according  to  the  quality  of 
the  milk  used  and  the  thoroughness  of  the  process.  The  average 
is  about  25  per  cent  of  fat. 


h 


FIG.  21. —  PARTS  OF  CENTRIFUGE:  BOTTLES. 

a,  f,  Spouts  for  milk  and  cream;  c,  outer  cylinder;  d,  inner  porous  cylin- 
der; 6,  e,  lids  of  cylinders;  ft,  receptacle  into  which  milk  is  first 
poured,  with  tube  at  bottom  leading  to  inner  cylinder;  i,  j,  bottles  for 
delivering  milk  and  cream. 

Condensed  or  evaporated  cream,  which  is  offered  in  market,  con- 
sists of  about  one-fourth  cream  and  three-fourths  other  ingredients 
of  milk,  the  whole  milk  having  been  evaporated  by  apparatus.  It 
is  therefore  a  natural  product,  easily  digestible  on  account  of  the 
dilution  of  the  cream  with  the  proteid  ingredients  of  the  milk, 
and,  unlike  much  condensed  milk,  it  is  not  artificially  sweetened.  It 
is  sometimes  mixed  with  malt  extract. 

Clotted  or  Devonshire  cream  is  skimmed  from  heated  milk,  so  that 
the  albumin  is  coagulated  with  it.  It  is  warmed  over  a  slow  fire  not 
above  150°  F.  Fothergill  wrote,  "Devonshire  cream  is  delicious 
with  preserved  ginger,  while  cream  and  maraschino  form  a  nutritive 
drink  for  the  affluent  consumptive." 

In  cooking,  suet  is  sometimes  added  to  replace  cream  and  impart 
additional  color  and  flavor  to  milk. 

Cream  is  one  of  the  most  wholesome  and  agreeable  forms  of  fat. 
It  is  often  eaten  too  rich,  and  may  disagree  on  that  account,  whereas, 
diluted  with  an  equal  bulk  of  water  or  of  lime  water,  it  is  well  borne. 
For  those  who  cannot  digest  milk  I  often  prescribe  three  or  four 


112         FOODS  AND  FOOD  PREPARATIONS 

tablespoonfuls  of  cream  in  a  tumblerful  of  Vichy,  which  makes  a  most 
agreeable  and  digestible  beverage.  It  is  an  excellent  substitute  for 
cod-liver  oil  in  pulmonary  tuberculosis,  for,  although  not  quite  so 
digestible,  most  persons  prefer  to  take  it.  It  is  an  excellent  food  also 
in  long-continued  suppurative  diseases,  such  as  empyema  or  tubercular 
joint  diseases.  It  should  be  avoided  in  flatulent  dyspepsia,  in  most 
forms  of  gastric  disease,  obesity  and  gallstones. 

It  is  useful  as  a  substitute  for  milk  when  diarrhoea  or  maras- 
mus, etc.,  occurs  in  infants.  It  should  be  diluted  considerably  when 
so  given. 

The  addition  of  strong  liquors  to  cream  lessens  its  digestibility 
just  as  heat  does,  for  alcohol  coagulates  and  toughens  the  proteid 
envelopes  of  the  fat  globules. 

Ice  cream  was  invented  by  a  Neapolitan  named  Florin  about  150 
years  ago.  It  is  a  frozen  product  of  cream,  sugar  and  flavoring  ma- 
terial, and  should,  contain  14  per  cent  of  cream.  When  very  simply 
made,  it  is  nutritious,  and  may  be  allowed  many  patients.  It  is  sooth- 
ing to  inflamed  throats  and  enjoyed  by  convalescents  from  fevers,  and 
children  who  object  to  milk  will  often  take  it.  It  should  be  eaten 
very  slowly,  so  that  it  may  become  well  warmed  in  its  passage  to  the 
stomach ;  otherwise  it  retards  digestion.  It  is  often  adulterated  with 
eggs,  farina,  etc. 

3.  Butter. —  Butter  is  made  from  cream  by  the  mechanical  agita- 
tion of  the  fat  globules,  which  are  thus  made  to  adhere  together  in 
small  masses.  The  rupture  is  accomplished  by  churning,  and  after 
the  butter  is  of  sufficient  density,  salt  in  small  proportion  is  added, 
and  the  butter  is  "worked"  over  with  a  spatula  and  frequently 
washed. 

Butter  contains  on  the  average  (according  to  Farrington  and  Woll) 
the  following  percentages: 

Water    13 

Fat    80  to  83 

Proteid  and  lactose   1 

Salt    (added)     3 

The  volatile  fatty  acids  (see  p.  55)  impart  to  butter  its  taste  and 
odor. 

The  quantity  of  casein  in  butter  may  roughly  be  estimated  by 
melting  a  specimen  in  a  test  tube,  when  the  casein  forms  a  layer  at 
the  bottom. 

Butter  should  not  have  less  than  0.5  to  2  per  cent  nor  more  than 
8  per  cent  of  salt  added.  Perfectly  fresh  butter  made  without  salt  is 
comparatively  tasteless  and  keeps  poorly.  The  decomposition  of  its 


ANIMAL  FOODS  113 

proteid  liberates  a  ferment  which  separates  fatty  acids  and  glycerin. 
Fresh  butter  if  kept  too  long,  especially  in  hot  weather,  soon  becomes 
rancid,  bitter,  and  unwholesome.  Fresh  butter  is  commonly  preferred 
throughout  southern  and  middle  Europe. 

Butter  is  adulterated  by  dealers  by  beating  it  up  with  water  and 
by  adding  other  fats,  especially  suet  and  oleomargarine.  The  sophis- 
tication with  water  is  easily  detected  by  melting,  when  the  sample 
separates  into  two  layers. 

Butter  which  contains  too  much  water  and  too  many  ingredients 
other  than  the  fat  has  not  been  sufficiently  "  worked,"  and  is  also 
likely  to  become  rancid  and  cause  violent  gastric  derangement. 
Very  thorough  washing  of  butter  when  first  made  will  remove  much 
of  its  proteid  substance  and  tend  to  prevent  its  fermentation;  and 
fresh  butter  which  has  once  become  rancid  may  be  rendered  less  so 
by  melting  and  shaking  it  in  boiling  water  which  is  several  times  re- 
newed and  then  pouring  it  into  ice-cold  water.  It  is  then  called 
"  smalt."  The  addition  of  salt  to  butter  in  the  strength  of  twenty  to 
twenty-five  grams  per  kilogram  postpones  or  prevents  the  fermenta- 
tion, and  sugars  or  sirups  in  which  the  butter  may  be  immersed 
have  the  same  effect.  So  also  does  protecting  it  from  atmospheric 
air  in  hermetically  sealed  jars  set  in  cold  water,  or  simply  keeping 
it  under  fresh  water  which  is  renewed  two  or  three  times  a  day. 

Pure  fresh-butter  fat  is  not  crystalline,  but  old  or  rancid  butter  fat 
becomes  so. 

Strong-tasting  butter  is  not  necessarily  unwholesome,  for  the  flavor- 
may  have  been  derived  from  the  cow  having  fed  upon  dead  leaves 
or  turnips,  and  butter  is  more  sensitive  than  milk  in  transmitting 
unpleasant  flavors. 

Butter  will  not  support  life  for  any  length  of  time  when  taken 
alone,  although  100  grams  (3*4  ozs.)  furnish  837  calories.  Garni vora 
fed  upon  an  exclusive  diet  of  meat  and  fat  do  not  grow  fat,  there- 
fore the  original  Banting  treatment  for  obesity  (see  Obesity)  has 
been  modified  by  Ebstein  and  others  by  the  free  addition  of  butter 
to  the  diet.  Taken  in  connection  with  other  foods,  however, 
butter  is  a  highly  digestible  and  nutritious  food,  and  it  has  been 
wittily  said  that  "if  bread  is  the  staff  of  life,  butter  is  its  golden 
head." 

For  weak  stomachs  the  digestion  of  butter  is  improved  by  spread- 
ing it  thoroughly  in  thin  layers  upon  bread,  or  allowing  it  to  soak 
into  hot  toast.  It  is  thus  prevented  from  floating  about  in  a  man- 
ner which  coats  the  food  and  walls  of  the  stomach  and  retards  gastric 
secretion.  Most  persons  eat  about  an  ounce  a  day  of  butter,  but  many 


114          FOODS  AND  FOOD  PREPARATIONS 

eat  double  that  quantity.     Its  annual  production  in  the  United  States 
exceeds  one  billion  pounds. 

The  use  of  oleomargarine  and  butterine  as  substitutes  for  butter 
are  described  under  the  heading  Fats  and  Oils,  page  228. 

4.  Buttermilk. —  Buttermilk  is  the  residual  milk  Jef t  after  churn- 
ing and  removing  the  fat.     It  is  wholesome  and  diuretic,  and  makes 
a  capital  beverage  for  those  patients  who  fancy  its  peculiar  sour 
taste.     It  contains  albumin  and  finely  coagulated  casein,  salts,  water, 
and  sugar,  which  is  largely  converted  into  lactic  acid. 

The  chemical  analysis  of  buttermilk  is  thus  given  by  Farrington 
and  Woll: 

Water  91.0 

Lactose  and   lactic-acid 4.0 

Casein  and  albumin    ,  4.0 

Fat    0.3 

Ash   0.7 

Its  fuel  value  is  about  that  of  skimmed  milk  — 165  calories  pei 
pint  —  and  its  composition  resembles  skimmed  milk,  but  it  contains 
a  little  less  protein  and  carbohydrate  and  a  little  more  fat.  A  pint 
of  it  contains  as  much  nourishment  as  two  ounces  of  bread  or  a  large 
potato.  It  should  be  drunk  fresh,  for  it  soon  decomposes.  Some 
patients  can  digest  it  who  are  unable  to  take  ordinary  milk.  In  those 
disorders  in  which  the  digestion  of  protein  and  fats  is  poor  it  may 
be  borne  better  than  milk. 

It  is  of  especial  value  in  chronic  gastric  catarrh  with  atrophy  of 
the  gastric  glands  (Eulenburg).  A  "buttermilk  cure"  is  sometimes 
practiced  after  the  manner  of  the  "whey  cure"  (see'  Dietetic 
"Cures"),  but  buttermilk  cannot  long  be  depended  upon  as  an  ex- 
clusive diet.  (For  artificial  buttermilk,  see  Lactone,  p.  93.) 

5.  Cheese. —  Cheese  is  composed  of  the  casein  of  milk  separated  by 
rennet,  together  with  some  of  the  fat  and  salts.     Cheese  forms  a 
highly  nutritious  food  and  an  important  article  of  commerce.     In 
countries  where  meat  is  scarce  and  dear  the  peasantry  consume  large 
quantities  to  supply  the  proteid  element  of  their  diet,  and,  weight  for 
weight,  cheese  contains  about  twice  as  much  protein  as  meat.     They 
use  for  this  purpose  the  heavier,  less  highly  flavored  cheeses.     The 
wealthy  classes  eat  cheese  more  as  a  condiment,  taken  after  meals, 
and  therefore  they  require  higher  flavored  varieties,  which  please  the 
palate  and  excite  the  secretion  of  gastric  juice.     Eaten  in  moderation, 
such  cheeses  are  an  aid  to  digestion.     Taken  with  milk,  cheese  tends 
to  reduce  the  size  of  the  coagulas  in  the  stomach.     Old  "  poor  "  cheese 
—  i.  o.,  cheese  made  without  fat,  consisting  of  almost  pure  casein 


ANIMAL  FOODS  115 

—  is  difficult  to  masticate  thoroughly,  and  is  slowly  dissolved  in  the 
gastric  juice,  hence  it  is  slowly  digested.  It  may  act  as  a  gastric 
irritant  and  be  hurried  into  the  intestine  to  excite  indigestion  there. 
Such  cheese  may  be  rendered  more  digestible  by  cooking  it  after 
grating  with  bicarbonate  of  potassium  in  the  proportion  of  a  quar- 
ter of  an  ounce  to  the  pound  of  cheese. 

About  250,000,000  pounds  of  cheese  are  annually  produced  in  the 
United  States  alone,  and  much  so-called  "  foreign "  cheese  is  pro- 
duced in  this  country. 

There  are  upwards  of  150  varieties  of  cheese  made  in  different 
countries,  but  a  few  only  of  the  better  known  kinds  may  be  mentioned 
within  the  limits  of  this  work.  In  general  the  properties  of  cheeses 
depend  upon  three  main  factors:  (1)  the  quantity  of  water  that 
they  contain,  which  chiefly  determines  their  hardness  or  softness ; 
(2)  the  quantity  of  fat  present,  which  in  skim  cheeses  is  reduced 
and  in  cream  cheeses  is  increased,  as  compared  with  the  normal 
fat  content  of  milk;  (3)  the  kind  and  degree  of  fermentation  proc- 
esses upon  which  the  flavor  largely  depends.  Many  additional  fac- 
tors, however,  enter  into  successful  cheese-making,  and  the  skill  with 
which  they  are  applied  determines  the  success  of  the  final  product. 
Such  for  example  are  the  varied  temperatures  employed  in  manu- 
facture, the  method  and  degree  of  fragmentation  of  the  curds,  the 
mixture  of  milk  and  cream  of  different  grades  of  fermentation,  the 
pressure  applied,  the  frequency  of  turning  to  expose  successive  sur- 
faces, the  scraping  of  mold  from  the  surface,  polishing,  bandaging^ 
the  duration  of  "curing"  or  "ripening"  and  the  temperature  and 
degree  of  moisture  at  which  it  is  applied,  the  nature  of  the  molds 
and  bacteria  which  are  introduced,  etc. 

The  quality  of  cheese  largely  depends  upon  the  richness  of  its  fat. 
In  the  richest  cheeses  made  of  whole  milk,  such  as  Stilton,  double 
Gloucester,  Gorgonzola,  Edam,  Cheshire  and  Roquefort,  cream  is 
added.  Single  Gloucester,  American,  and  similar  cheeses  are  made 
from  milk  from  which  the  cream  has  been  removed.  Dutch,  Suffolk, 
and  Parmesan  cheeses  are  also  made  from  skimmed  milk,  and  are 
"  poor."  Being  nearly  pure  casein,  they  are  hard  to  digest  in  bulk. 
These  latter  varieties  keep  well,  and  become  hard  enough  to  be  grated. 
Fat  separates  the  flocculi  of  casein  and  makes  eheeses  soft,  friable, 
and  rich,  but  they  sooner  decay. 

The  varieties  of  cheese  differ  in  percentage  composition,  but  in 
general  they  may  be  said  to  contain  from  35  to  55  per  cent  of  water 
and  from  10  to  20  per  cent  of  fats,  20  to  30  per  cent  of  casein,  and 
about  6  per  cent  of  salts. 


116          FOODS  AND  FOOD  PREPAEATIONS 

Cheese  is  usually  prepared  from  sweet  milk.  The  coagulation  is 
accomplished  in  a  few  minutes  to  a  few  hours  by  the  addition  of  the 
ferment  rennin  with  gentle  heat  (120°  F.).  The  heat  secures  firmer 
coagulation.  Casein  also  may  be  coagulated  by  acids.  A  little  salt 
is  added;  the  curd  is  strongly  pressed  in  a  mold,  and  the  expressed 
fluid  is  called  "whey."  The  curd  is  then  salted  and  dried  on  the 
surface  by  frequent  turning  in  the  air.  The  harder  cheeses  are  made 
under  higher  temperature  and  pressure.  Cheese  is  kept  for  a  time 
to  "  ripen/'  by  fermentation  or  decomposition.  If  the  decomposition 
goes  too  far,  it  develops  leucin  and  tyrosin;  the  casein  may  become 
soluble  in  water,  producing  soda  albuminate  and  peptones.  The 
"  riper  "  a  cheese  the  greater  is  its  value  as  a  condiment. 

During  the  ripening  volatile  fatty  acids  are  evolved  from  the  fatty 
matter  present,  which  occasion  the  odor  and  flavor.  The  casein 
also  undergoes  change,  and  is  partially  converted  into  fat.  It  may 
putrefy  and  evolve  ammonia,  or  become  poisonous.  Eipening,  when 
not  carried  too  far,  makes  cheese  more  friable,  and  hence  more 
digestible. 

Cream  cheese  is  fresh,  and  usually  not  ripened. 

Pot-cheese,  Dutch  or  Cottage  cheese,  is  made  from  the  curds  of  sour 
milk  or  buttermilk  and  is  produced  by  natural  lactic-acid  fermen- 
tation and  heat.  It  is  squeezed  dry,  salted,  and  eaten  with  cream, 
butter  or  spice.  It  contains:  Water,  60.27  per  cent;  casein,  24.84 
per  cent;  fat,  7.33  per  cent;  ash,  4.02  per  cent;  milk  sugar  and  lactic 
acid,  3.54  per  cent. 

Whey  cheese  is  made  from  mildly  sour  whey  evaporated  by  boiling, 
and  with  addition  of  cream.  It  is  eaten  in  Scandinavia. 

American  cheddar  is  manufactured  from  whole  milk  heated  to  86° 
F.,  to  which  rennet  is  added.  According  to  Farrington  and  Woll  its 
percentage  composition  when  fresh  or  "  green  "  averages :  water,  37 ; 
fat,  34;  casein,  24;  lactose,  lactic  acid  and  ash,  5.  The  milk  al- 
bumin is  not  precipitated  by  rennet.  In  "  curing "  or  drying,  the 
cheese  loses  about  3  per  cent  of  water,  and  peptones,  amids,  etc.,  de- 
velop in  the  curd. 

The  two  soft  cheeses  most  used  in  this  country  are  Camembert 
and  Brie. 

Camemlert  is  a  cheese  made  of  whole  milk,  which  is  very  care- 
fully dried  under  regulated  temperature.  It  is  covered  with  a  dark 
red  mold,  and  the  interior  acquires  a  moist  creamy  consistence.  The 
rennet  fermentation  is  conducted  at  a  low  temperature  and  is  con- 
sequently a  slow  process.  The  curd  is  not  broken,  but  placed  in 
molds  to  drain,  and  is  frequently  turned.  The  curing  occupies  some- 


ANIMAL  FOODS  117 

what  more  than  a  month  in  a  cool,  damp  cellar.  This  cheese,  as 
well  as  the  following  variety,  is  made  in  St.  Lawrence  County,  Pa., 
as  well  as  in  Europe. 

Brie  is  manufactured  in  three  grades  of  richness,  according  to 
whether  the  milk  is  whole,  partly  skimmed,  or  skimmed.  The  curing 
results  in  softening  the  casein  to  a  moist,  almost  creamy  consistence, 
and  imparting  a  typical  rich  flavor.  Putrefactive  molds  develop  on 
the  outer  surface. 

Neufchatel  is  made  by  rennet.  The  curd  is  uncured,  soft,  and 
faintly  acid.  In  taste  it  resembles  slightly  acid  clotted  milk,  and  it 
should  melt  at  the  mouth  temperature. 

Limburger  is  commonly  manufactured  from  unskimmed  milk  by 
the  agency  of  putrefactive  bacteria.  It  has  a  pungent  taste  and 
strong  odor  of  putrefaction.  Its  color  is  reddish  yellow.  In  ripen- 
ing the  cheese  softens  from  the  outside  inward. 

Sage  cheese  is  a  common  American  variety  to  which  an  infusion 
of  leaves  of  the  sage  plant  imparts  their  flavor  and  a  greenish  color. 

Pineapple  cheese  is  a  very  firm  variety  of  an  orange  color,  pressed 
in  a  mold  to  resemble  the  pineapple  fruit. 

Stilton  is  derived  from  fresh  sweet  milk  with  rennet.  The  curds 
after  straining  and  drying  in  cloths  by  a  squeezing  process  are  al- 
lowed to  sour.  Curds  of  different  ages,  and  degrees  of  sourness 
are  mixed  together,  salted,  and  drained  in  perforated  cylinders. 
A  white  mold  coats  the  surface.  The  curing  occupies  several 
months.  The  cheese  is  somewhat  soft,  faintly  yellowish  within, 
but  gray  on  the  surface.  The  cut  surface  is  irregularly  marked  with 
mold. 

Cheshire  is  a  well  flavored  granular,  soft  English  cheese  manu- 
factured from  ripe  whole  milk,  although  skimmed  milk  and  cream 
of  different  ages  are  mingled.  The  curd  is  ground,  salted,  colored, 
and  allowed  to  ferment  in  perforated  cylinders,  like  Stilton,  in 
which  it  acquires  a  white  mold.  The  curing  process  requires  about 
a  month. 

Roquefort  is  a  hard  cheese  made  in  the  department  of  Aveyron, 
France,  from  goat's  milk,  partly  skimmed  and  coagulated  with  rennet. 
The  curd  is  then  pressed  for  half  a  day,  dried  for  ten  or  twelve 
days,  and  ripened  in  caves.  This  cheese  is  streaked  with  bluish  lines, 
which  are  formed  by  the  addition  of  a  mold  which  grows  on  stale 
rye  bread.  This  cheese  is  also  made  along  the  shores  of  the  Great 
Lakes  in  this  country,  where  conditions  of  climate,  pasturage,  and 
water  favor  its  production. 

Swiss  cheese   or  Schweizer  of  which   Emmenthaler  is   a   type,   is 


118          FOODS  AND  FOOD  PREPARATIONS 

a  firm,  friable,  pale  cheese,  perforated  with  small  holes  uniformly 
distributed,  which  are  due  to  gases  of  fermentation  developed  by 
curing.  The  rennet  curd  is  cut  into  fragments  and  heated  to  140° 
F.  It  is  subsequently  bandaged  and  pressed. 

Edam  is  a  hard,  dark  red,  Dutch  cheese,  shaped  like  a  cannon  ball 
and  made  from  sweet  skimmed  milk.  The  curd  is  forcibly  broken 
into  minute  fragments,  warmed  to  85°  F.,  drained,  pressed  in 
spherical  molds,  salted  by  dipping  in  brine,  and  rubbed.  A  white 
mold  covers  them  during  the  month  of  curing.  They  are  finally 
cleaned,  dried  and  coated  with  linseed  oil,  a  dark  red  pigment,  and 
tinfoil.  The  flavor  of  this  cheese  improves  continuously  for  six 
months  and  more. 

Gruyere  was  originally  a  hard  Swiss  cheese,  but  is  now  made  also 
in  France  and  elsewhere.  It  is  dry,  aerated  with  large  holes,  and  it 
may  be  crumbled.  It  is  manufactured  in  three  grades,  according 
to  the  degree  of  skimming  of  the  milk,  and  the  curd  is  cooked 
a  short  time  before  it  is  pressed.  It  has  a  somewhat  saltish 
taste. 

Gorgonzola  is  a  Piedmontese  cheese  made  with  hot  and  cold  curds 
from  two  milkings,  which  do  not  perfectly  unite,  but  which  form 
minute  interstices  in  which  a  green  mold  called  "parsley "  grows 
and  imparts  a  high  flavor.  The  curd  is  hung  in  hempen  cloths  to 
ferment.  It  is  well  salted. 

In  the  United  States  much  of  the  cheese  manufactured  is  of  the 
common  sort  called  "  American  cheddar,"  but  Neuchatel,  Stilton, 
pineapple,  and  other  more  highly  flavored  varieties  are  also  exten- 
sively produced.  "  Swiss  "  cheese  is  made  in  Ohio  and  Wisconsin. 
An  imitation  cheese  is  also  prepared  from  a  mixture  of  one  part  lard 
and  two  or  three  parts  milk,  mixed  or  emulsionized  at  150°  F. 
This  emulsion  is  then  added  with  buttermilk  to  skimmed  milk,  so 
that  the  finished  product  contains  about  14  per  cent  of  lard  (Cald- 
well). 

Toasted  cheese  is  one  of  the  most  indigestible  articles  of  diet, 
unless  the  cheese  is  new,  "  poor,"  and  cut  thin.  "  Welch  rarebits  " 
made  of  melted  cheese  with  butter  and  beer  added,  are  difficult  of  di- 
gestion, although  nutritious  when  absorbed.  It  is  an  old  saying  of 
such  cheese  that  it  is  "  gold  in  the  morning  but  lead  at  night." 

Certain  low  organisms,  molds,  fungi,  etc.,  flourish  in  cheese  and 
make  it  very  irritant  to  the  stomach.  Such  are  the  Aspergillus 
glaums  and  Sporendoncum  casei,  both  of  which  give  a  red  color,  the 
cheese  mite  (A earns  domesticus)  and  the  maggots  of  a  fly  (Piophilia 
casei).  Bnd  cheese  lias  been  known  to  produce  poisonous  symptoms 


ANIMAL  FOODS  119 

(see  Ptomaine  Poisoning)  resembling  those  of  poisoning  by  sausage 
meat. 

Cheese  food,  devised  by  J.  J.  Angus,  is  made  from  cheddar  cheese, 
ground  and  mixed  with  evaporated  whey.  It  is  then  compressed 
into  cakes,  and  forms  a  soft  mass  with  mild  flavor. 

Plasmon  is  an  albumin  food  made  from  milk  from  which  the  fat 
has  been  removed.  It  is  practically  a  dried  form  of  casein.  It  is 
a  tasteless,  odorless,  white,  dry  powder,  soluble  in  water.  It  may 
be  given  every  hour  or  two  in  teaspoonful  doses  in  ten  tablespoonfuls 
of  water,  or  with  an  equal  quantity  of  sugar  an  ounce  of  plasmon 
may  be  stirred  into  half  a  pint  of  boiling  milk.  It  may  be  added 
to  broths  and  gruels,  or  to  such  starchy  foods  as  boiled  rice  or 
mashed  potatoes.  This  food  contains  over  90  per  cent  of  pure  protein 
in  very  digestible  form.  Plasmon  biscuits  and  a  plasmon  chocolate 
are  also  manufactured. 

Nutrose  or  casein-sodium  is  a  form  of  milk  casein  which  may  be 
added  in  half-ounce  doses  to  broths,  gruels,  or  cocoa,  in  which  it 
is  soluble.  It  contains,  according  to  Bruno  Oppler,  about  90  per 
cent  of  pure  protein.  It  furnishes  a  lessened  volume  of  feces  when 
this  is  desirable  after  operations  upon  the  intestines. 

Sanose  is  an  albuminous  food  consisting  of  80  per  cent  of  powdered 
casein  and  20  per  cent  of  egg  albumen.  It  is  a  white,  odorless, 
tasteless  powder  forming  an  emulsion  in  water.  It  may  be  given 
in  milk,  cocoa,  purees,  or  soups.  From  two  to  six  tablespoonfuls  may 
be  given  daily. 

6.  Whey  is  derived  from  the  milk  of  several  animals,  such  as  the 
sheep,  goat,  mare,  and  ass,  as  well  as  the  cow.  When  milk  has 
been  standing  for  some  time  in  the  air  it  becomes  contaminated 
with  bacteria,  which  cause  spontaneous  coagulation,  and  whey  is 
squeezed  out  of  the  contracting  clot;  but  this  is  sour  and  not  so 
good  as  that  made  by  rennet.  As  ordinarily  prepared  whey  is  the 
residuum  of  milk  from  which  the  casein  and  fat  have  been 
squeezed  out  as  cheese  by  the  coagulating  action  of  the  ferment 
rennin. 

According  to  Farrington  and  Woll  it  possesses  the  percentage  com- 
position: "\Vater,  93;  lactose,  o;  albumin,  0.8;  ash,  0.6;  fat,  0.3. 
Hence  it  is  practically  an  aqueous  solution  of  milk  sugar,  whitish, 
translucent  and  opalescent.  It  is  liable  to  turn  sour,  but  is  fairly 
digestible  even  then,  and  its  taste  may  be  disguised  by  the  addition 
of  nutmeg  and  sugar. 

It  makes  a  palatable,  mildly  diuretic  drink,  which  is  enjoyed  bv 
invalids.  In  Europe  several  "  whey  cures "'  have  been  established 


120  FOODS  AND   FOOD   PREPARATIONS 

for  the  treatment  of  renal  disease,  dropsical  affections,  etc.,  but 
whe}r  is  not  in  any  case  a  specific,  and  its  dietetic  value  is  greatly 
overrated.  (See  Whey  Cure.) 

Yeo  gives  the  following  simple  directions  for  the  preparation  of 
whey  for  invalids:  Boil  a  pint  of  milk  with  one  to  two  teaspoonfuls 
of  lemon  juice,  strain  in  muslin,  and  express  all  fluid  from  the  curd. 
Break  the  curd  up  first,  and  much  fat  and  some  finely  divided  casein 
will  go  into  whey.  Add  beef  tea  or  milk  juice,  or  egg  yolk  in  hot 
water. 

Wheyn  is  a  patented  beverage  made  from  a  sour  whey,  sometimes 
treated  with  hops,  or  charged  with  carbonic  acid. 

Eggs 

About  nine  billion  eggs  are  produced  annually  in  the  United 
States  and  in  1907  the  total  value  of  the  poultry  and  egg  product 
of  the  United  States  was  estimated  by  the  Secretary  of  Agriculture 
at  $600,000,000,  exceeding  that  of  wheat.  Eggs  contain  all  the 
ingredients  necessary  to  support  life  and  develop  the  organism.  Like 
milk,  they  constitute  a  "  complete  "  food,  for  out  of  an  egg  the  entire 
structure  of  the  bird  —  its  bones,  nerves,  muscles,  viscera,  and  on 
some  birds  feathers  —  are  developed  previous  to  hatching.  The  in- 
ner portion  of  the  shell  is  dissolved  by  phosphoric-acid  to  furnish 
phosphates  for  the  bones. 

The  average  weight  of  a  hen's  egg,  according  to  Bauer,  is  50 
grams,  or  about  1%  ounce,  divided  as  follows:  Shell,  7;  white, 
27 ;  yolk,  16  grams.  The  eggs  of  pullets  are  smaller  than  those  of 
old  hens. 

Hens'  eggs  principally  are  used  for  food,  but  the  eggs  of  ducks, 
geese,  and  guinea-fowl  are  eaten  also,  and  occasionally  those  of  such 
wild  birds  as  the  plover  and  sea  birds.  The  eggs  of  these  various 
species  of  birds  have  their  distinctive  flavor.  Along  the  Texan  coast 
the  eggs  of  gulls,  terns,  and  herons  were  formerly  gathered  for  food, 
those  of  the  gull  and  murre  on  the  Farallone  Islands  off  the  coast  of 
California,  and  those  of  the  laughing  gull  off  the  eastern  coast  of 
Virginia. 

Terrapin  eggs  are  eaten  together  with  the  flesh  of  the  animal,  and 
various  forms  of  fish  eggs  are  esteemed  for  food,  as  those  of  the 
sturgeon  (caviare)  and  shad  roe. 

The  shell  of  a  lien's  egg  weighs  about  one  hundred  grains.  Its 
color  boars  no  relation  to  the  nutrient  value  of  the  egg,  but  white 
shells  are  heavier  than  brown.  An  egg  consists  approximately  of  — 


ANIMAL  FOODS  121 

Shell — 1 1  parts     Carbonate  of  lime. 

Yolk — 32  parts:     Proteid    (vitellin)     15.7  per  cent. 

Fat  33.3         " 

Ash     1.1 

Water    49.5 


Total  calories   1,705 


White — 57  parts :   Proteid    12.3  per  cent. 

Fat 2         " 

Ash    6 

Water    86.2 


Total  calories   250 

The  yolk  is  very  complex.  Besides  the  proteid  vitellin,  it  con- 
tains three  fats,  coloring  matter,  nuclein,  lecithin,  and  salts  of  iron, 
calcium,  magnesium,  and  potassium. 

Egg  albumen  is  not  pure,  but  consists  of  four  albuminoid  and 
mucoid  bodies,  the  chief  of  which  is  oval- 
bumin,  together  with  a  trace  of  carbo- 
hydrate. The  phosphorus  equivalent  is 
0.03  per  cent  phosphoric  acid  (C.  P.  Lang- 
worthy),  whereas  that  of  the  yolk  exceeds 
1  per  cent. 

If  the  absorption  of  eggs  from  the  in- 
testine is  delayed,  decomposition  ensues 
with  production  of  sulphuretted  hydrogen 
and  ammonia,  which  cause  considerable  en- 
teric disorder.  The  yolk  of  egg  is  partic- 
ularly responsible  for  this.  It  is  therefore 

a  matter  of  great  importance  to  serve  only 

.  .  ,  ,      ,    ,  ,      „      ,    ,     .       , . ,       FIG.    22. —  DIAGRAM    OF    A 

eggs  which  are  absolutely  fresh  to  invalids.       HEN'S  EGG  SHOWING  THE 

No  egg  having  an  odor  of  stale,  old  straw       PROPORTION    OF    INGREDI- 

ENTS 

should  ever  be  offered.     There  are  two  sim- 
ple methods  by  which  the  nurse  may  test  the  freshness  of  an  egg: 

1.  Hold  the  egg  between  the  hands  so  that  the  light  of  a  candle 
shines  through  it.     If  fresh,  it  is  more  transparent  in  the  center;  if 
stale,  at  the  poles. 

2.  Make  a  solution  of  two  ounces  of  common  salt  in  a  pint  of 
water.     An  egg  one  day  old  will  sink  in  this  solution,  but  will  not 
quite  reach  the  bottom;  an  egg  three  days  old  will  barely  float  be- 
neath the  surface,  and  an  egg  a  fortnight  old  will  float  above  the 
surface,  only  partially  dipping  beneath  it   (Siebel).     This  difference 
is  due  in  part  to  loss  of  water,  which  after  ten  days  equals  1.60  per 
cent;  after  twenty  days,  3.16  per  cent;  and  after  thirty  days,  5  per 
cent.     It  is  also  due  in  part  to  development  of  gases  of  putrefaction. 


122         FOODS  AND  FOOD  PREPARATIONS 

With  some  persons  eggs  have  a  slight  aphrodisiac  effect,  and 
they  also  promote  costiveness.  They  should  not  be  eaten  in  cases  of 
flatulent  dyspepsia,  gastric  dilatation,  or  any  form  of  severe  gastric 
derangement.  The  flavor  of  eggs  is  modified  by  the  food  of  the  hen, 
those  from  hens  fed  on  nitrogenous  food  instead  of  carbohydrates  have 
poor  odor  and  flavor  and  small  yolks.  An  excess  of  onions  in  the 
hen's  diet  imparts  the  strong  odor  and  taste  of  the  vegetable  to  the 
eggs  laid  about  fifteen  days  after  such  food  has  been  eaten.  Eggs 
packed  in  stale  bran  or  straw,  or  kept  near  decaying  apples,  acquire 
a  bad  flavor.  Microorganisms  may  penetrate  the  eggshells  and  give 
rise  to  fermentation  and  decomposition. 

Raw  Eggs. —  Whole  raw  eggs  are  very  popular  in  dietetics  at 
present,  and  they  are  often  prescribed  when  a  nutritious,  highly  con- 
centrated diet  is  desired,  and  in  cases  of  tuberculosis,  some  forms  of 
amemia,  and  various  wasting  diseases;  sometimes  from  eight  to  ten 
or  twelve  are  given  daily  if  they  can  be  digested.  They  may  be 
advantageously  combined  for  such  purposes  with  milk  and  salt  or 
cod-liver  oil,  meat  broths,  soups,  and  purees.  Beaten  white  of  egg 
may  be  added  to  coffee,  cocoa,  wine,  cream,  or  sweetened  water. 

Eggnog  is  very  nutritious,  and  is  extensively  prescribed  in  some 
non-febrile  diseases,  especially  for  the  forced  alimentation  of  phthisis, 
neurasthenia  and  melancholia,  and  there  are  occasional  cases  of  bilious 
habit  in  which  eggs  only  can  be  digested  when  beaten  in  wine,  but 
the  combination  of  egg,  milk,  and  sugar  with  alcohol,  which  con- 
stitutes eggnog,  may  produce  nausea  and  vomiting  in  a  feeble  stomach, 
particularly  in  fever. 

Egg  albumen,  when  eaten  raw  or  almost  raw  and  properly  diluted 
with  milk  or  water,  is  well  absorbed.  It  also  may  be  predigested, 
and  it  should  be  flavored  with  lemon  juice,  or  sherry  or  other  wine, 
coffee,  cocoa,  or  cream,  and  sweetened  water;  otherwise  it  is  taste- 
less and  disagreeable,  and  but  few  can  continue  to  eat  it  in  any  con- 
siderable quantity.  (See  Eeceipts,  Preparations  of  Eggs.)  When 
the  fresh  white  egg  albumen  is  beaten  it  encloses  bubbles  of  air 
which  expand  by  heat  when  the  albumen  is  mixed  with  dough,  mak- 
ing it  porous,  as  in  the  case  of  sponge-cake.  Old  eggs  lose  this 
quality  of  frothiness. 

Egg  albumen  is  used  by  Ewald  to  prepare  fresh  albuminate  of 
iron.  He  adds  two  tablespoonfuls  of  a  solution  of  one  part  of  white 
of  eo-cr  jn  two  of  water,  to  a  teaspoonful  of  a  2  or  3  per  cent  solution 
of  ferric  chloride.'  To  be  taken  through  a  tube. 

Albumen  water  is  used  as  a  beverage  in  fevers.  The  whites  of  two 
or  three  eggs  are  beaten  with  lemon  juice  in  a  half  pint  of  water.  As 


ANIMAL  FOODS  123 

the  white  of  one  egg  furnishes  only  15  calories,  it  does  not  supply 
much  nutriment. 

The  Cooking  of  Eggs. —  Albumen,  or  the  "  white  "  of  egg,  is  altered 
physically  but  not  chemically  by  processes  of  cooking.  At  about  134° 
F.  delicate  fibrillae  of  coagulated  albuminous  material  begin  to  stretch 
through  the  substance,  and  they  increase  with  the  temperature  up 
to  160°  F.  The  fibrilla?  are  so  numerous  that  the  entire  mass  is 
coagulated,  but  is  still  of  a  soft  or  gelatinous  consistence. 

If  the  coagulated  albumen  is  heated  still  further,  it  becomes  more 
and  more  dense,  hard,  dry,  and  brittle.  When  heated  beyond  the 
boiling  point,  or  212°  F.,  it  forms  a  very  tenacious,  gluey  substance, 
which  can  be  used  as  a  cement  for  mending  broken  china. 

Eggs  baked  in  puddings  or  in  any  other  manner  form  one  of 
the  most  insoluble  varieties  of  albumen  possible.  A  raw  egg  is  or- 
dinarily digested  in  the  stomach  in  one  and  a  half  hour,  but  a  baked 
egg  requires  from  three  and  a  half  to  four  hours. 

Eggs  cooked  for  persons  with  delicate  digestions,  instead  of  being 
"boiled"  in  water  at  212°  F.,  should  be  placed  in  water  at  a  tem- 
perature between  170°  and  180°  F.,  and  immersed  for  fully  ten  min- 
utes, at  the  end  of  which  time  they  will  be  found  of  a  uniform 
gelatinous  consistence,  very  palatable,  and  not  too  tough  to  be  readily 
acted  upon  by  the  gastric  juice.  If  a  cooking  thermometer  is  not 
at  hand,  the  water  may  be  brought  previously  to  the  boiling  point 
and  then  set  aside,  when  in  a  moment  or  two  it  will  cool  to  the 
proper  temperature.  This  should  be  a  little  above  the  coagulation 
point  of  the  egg  albumen  (134°  F.),  because  the  process  of  rais- 
ing the  temperature  of  the  egg  is  a  slow  one,  and  the  water  loses 
heat  in  warming  the  egg  (Williams).  Eggs  cooked  in  this  manner 
are  found  to  have  the  yolks  more  firmly  coagulated  than  the  white, 
which  remains  quite  tender.  A  practical  way  of  attaining  the  above 
result  is  to  pour  a  quart  of  recently  boiled  water  over  two  eggs  in 
a  bowl  and  let  them  stand  for  ten  or  twelve  minutes. 

Another  excellent  way  to  cook  an  egg,  as  suggested  by  Henry, 
is  to  immerse  a  teacup  in  boiling  water  until  it  becomes  thoroughly 
heated.  It  is  then  removed  and  the  egg  is  broken  and  dropped 
into  it,  and  the  cup  may  be  wrapped  in  a  cloth.  Sufficient  heat  is 
retained  by  it  to  cook  the  egg  without  water  and  remove  any  raw 
taste. 

The  yolk  really  coagulates  at  a  lower  temperature  than  the  white, 
although  as  eggs  are  commonly  cooked  it  does  not  have  an  oppor- 
tunity to  coagulate  first.  The  yolk  is  composed  of  albumen  and 
casein  with  fat.  In  the  ordinary  rapid  cooking  of  eggs  in  boiling 


124         FOODS  AND  FOOD  PREPARATIONS 

water  the  white  is  firmly  coagulated  before  there  is  time  for  the  temper- 
ature of  the  interior  of  the  egg  to  be  raised  thoroughly,  and  conse- 
quently the  yolk  is  softer  than  the  white.  The  shell  of  the  egg  facili- 
tates the  process  of  slow  cooking  of  the  albumen  by  protecting  the  in- 
terior and  preventing  the  escape  of  the  contents  by  solution,  just  as  in 
the  cooking  of  fish  or  flesh  in  water,  the  latter  should  be  hot  enough 
immediately  to  form  an  external  coagulum  of  albumen  sufficiently 
dense  to  prevent  the  diffusion  of  albuminous  material  and  salts  into 
the  water. 

Custards  composed  largely  of  eggs,  although  unfit  in  active  fever, 
are  very  useful  adjuncts  to  a  convalescent  dietary  in  recovery  from 
typhoid  fever  or  other  acute  diseases. 

In  the  making  of  omelettes  and  "  scrambled "  eggs  the  white  is 
thoroughly  mixed  with  the  yolk,  and  the  egg  is  more  digestible  than 
when  fried  or  cooked  so  much  that  the  albumen  is  hard. 

Preservation  of  Eggs. —  Eggs  decompose  from  the  admission  of 
germs  through  their  porous  shells.  To  prevent  this  occurrence  it 
is  necessary  to  protect  the  eggs  from  contact  with  air.  When  first 
laid,  eggs  have  a  protective  mucilaginous  coating,  which  is,  how- 
ever, removed  by  washing.  They  may  be  coated  with  varnish,  par- 
affin, tinfoil,  butter,  glycerin,  vaseline,  or  any  fat  or  oil  not  liable 
to  become  rancid.  A  2  or  3  per  cent  solution  of  salicylic  acid  may 
be  added  to  the  oil.  Packing  in  sawdust  or  bran  also  excludes  the 
air  to  a  slight  extent.  Lime  with  cream  of  tartar  preserves  eggs  when 
coated  with  it,  but  alters  their  taste. 

According  to  C.  F.  Langworthy  (U.  S.  Department  of  Agricul- 
ture Bulletin  No.  128)  the  best  preservative  substance  is  a  10 
per  cent  solution  of  water-glass,  in  which  eggs  will  keep  fresh  for 
three  and  one-half  months.  Eggs  also  preserve  their  freshness  for 
as  much  as  a  year  in  cold  storage  at  30°  to  40°  F.  Eggs  so  stored 
should  be  turned  twice,  a  week  to  prevent  gravitation  of  the  yolk, 
causing  its  adhesion  to  the  shell. 

Eggs  are  also  preserved  by  drying,  canning,  and  similar  processes, 
when  designed  for  shipment  upon  long  voyages. 

Evaporated  or  desiccated  eggs  are  dried  in  vacua  or  otherwise  by 
currents  of  warm  air.  Salt  or  sugar  may  be  added,  and  the  eggs  are 
ground.  Such  eggs  keep  well,  and  often  are  used  by  bakers. 

Meats 
The  Consumption  of  Meat. —  The  universal  consumption  of  meat 

l>y  civilized  man  is  of  more  recent  origin  than  is  generally  supposed. 
McCulIooh  states  (Statistical  Account  of  the  British  Empire,  vol.  ii, 


ANIMAL  FOODS  125 

p.  502)  that  "so  late  as  1763  the  slaughter  of  bullocks  for  the  supply 
of  the  public  markets  was  a  thing  wholly  unknown  even  in  Glasgow, 
though  the  city  had  then  a  population  of  thirty  thousand." 

In  the  past  decade  or  two  the  consumption  of  meat  has  increased 
enormously,  especially  in  England,  owing  to  the  development  of 
cheap  refrigerating  processes,  canning,  and  increased  facilities  of 
transportation  of  live  cattle.  The  beef  from  Australian  and  New 
Zealand  cattle  is  obtainable  in  London,  and  that  of  Texan  cattle  in 
Xew  York  in  a  state  of  perfection  and  cheapness  which  exceeds 
that  of  animals  raised  close  at  hand.  There  is  a  popular  belief  that 
the  eating  of  meat  increases  both  bodily  vigor  and  mental  capacity, 
and  that  a  man  fed  upon  animal  food  is  livelier,  keener,  and  stronger 
than  the  exclusive  vegetarian.  (See  Animal  and  Vegetable  Foods 
Compared,  p.  29.)  This  comparison  may  not  hold  in  all  cases,  nor 
with  all  people  and  tribes  of  man  —  as,  for  example,  the  Japanese  and 
many  African  tribes  —  but  it  applies  very  well  to  those  who  have  to 
meet  the  exigencies  of  advanced  civilization.  Liebig,  in  extolling 
the  advantages  of  a  liberal  meat  diet,  wrote :  "  It  is  certain  that  three 
men,  one  of  whom  has  had  a  full  meal  of  meat  and  bread,  the  second 
cheese  or  salt  fish,  and  the  third  potatoes,  regard  a  difficulty  which 
presents  itself  from  entirely  different  points  of  view." 

It  is  true,  however,  that  too  much  meat  is  eaten  by  many  persons 
for  maintenance  of  the  best  health.  The  annual  per  capita  consump- 
tion of  meat  has  almost  doubled  during  the  past  half  century.  It  is 
estimated  in  pounds  as  follows :  In  the  United  States,  147 ;  England, 
100;  France,  77;  Germany,  64;  Russia,  50;  Italy,  24. 

Very  large  quantities  of  meat  —  much  more  than  is  necessary  for 
sustenance  —  are  absorbed  when  eaten,  although  a  few  undigested 
muscle  fibers  may  appear  in  the  stools. 

An  exclusive  cooked  meat  diet,  if  long  continued,  tends  to  pro- 
duce scurvy,  and  on  the  other  hand  the  prolonged  absence  of  meat 
favors  the  occurrence  of  anaemia  in  many  persons.  In  general,  those 
diseases  in  which  an  exclusive  meat  diet,  or  a  diet  composed  almost 
exclusively  of  animal  food,  with  perhaps  a  minimum  of  dry  bread, 
is  found  temporarily  beneficial,  are  the  following:  Flatulent  dyspep- 
sia, chronic  gastritis  and  gastric  catarrh  and  dilatation,  diabetes,  intes- 
tinal dyspepsia,  phosphaturia,  obesity,  and  some  cases  of  chronic  dys- 
entery. Meat  should  also  enter  largely  into  the  diet  of  consumptives 
and  anaemic  subjects. 

It  is  well  to  prohibit  the  consumption  of  meat  in  fevers,  acute 
and  advanced  chronic  Bright's  disease,  acute  gout  and  rheumatism, 
and  to  reduce  it  in  lithgemia  and  oxaluria. 


126 


FOODS  AND  FOOD  PREPARATIONS 


FIG.  23. —  A  PIECE  OF  BEEF  MAGNIFIED. 
(U.  S.  Dept.  of  Agri.,  Bui.  56,  Office  of  Expt.  Sta- 
tions.) 


Structure  and  Com- 
position of  Meats. — 
Meat  from  any  animal 
is  composed  of  muscu- 
lar fibers,  but  it  neces- 
sarily contains  those 
structures  which  were 
intimately  associated 
with  them,  such  as 
connective  tissues, 
blood  vessels,  nerves, 
and  lymphatic  vessels, 
and  more  or  less  adi- 
pose tissue.  Meat 
which  is  very  fat  con- 
tains comparatively 
little  water  as  well  as 
less  proteid  than  lean 
meat. 


The  toughness  of  meat  is  due  to  thickness  of  the  walls  of  its  muscle 
tubes  and  excess  of  connective  tissue  bundles  associated  with  them, 
which  latter  is  thicker  in  older  animals  than  in  young.  Tough  meat 
may  be  made  more  tender  by  pounding,  to  soften  the  connective 
tissue.  (Fig.  24.) 

The  flavor  of  meat 
varies  with  the  ani- 
mal's age,  its  food, 
breed,  and  condition 
when  killed.  The  meat 
of  male  animals  (ex- 
cepting pigs)  is  usual- 
ly higher  flavored  than 
that  of  females. 

Meats  contain  al- 
buminoids and  gela- 
tinoids.  The  latter, 
through  action  of  hot 
water  or  steam,  arc 
converted  into  gelatin. 

Meat       "  extractives/' 

.,  .  FIG.  24. —  BEEF  FIBERS  HIGHLY  MAGNIFIED. 

nitrogen       extractives.         /T,   0   „          *  *     •    T>  i    -o   r\az       t  ^ 

(L.  S.  Dept.  of  Agn..  Bui.  06,  Office  of  Expt. 

or    "meat    bases."    as  Stations.) 


ANIMAL  FOODS 


127 


they  are  variously  called,  are  cleavage  products  of  albuminoids  and 
gelatinoids,  soluble  in  water  and  alcohol.  Their  special  use  in  dietetics 
is  described  on  p.  140. 

The  following  table  (condensed)  by  Atwater  and  C.  F.  Lang- 
worthy  gives  the  average  chemical  composition  of  various  meats. 
It  should  be  stated  that  the  different  cuts  of  meat  from  the  same 
animal  present  slight  differences  in  relative  quantities  of  fats,  pro- 
tein, etc. : 

Composition  of  Meats   (Atwater  and  Langworthy). 


Water. 

Protein. 

Fat. 

Calories 
per  Ib. 

43  8 

13.9 

21.2 

1,135 

52  4 

19  1 

16  1 

975 

68  3 

20.1 

7.5 

695 

51  2 

15  1 

14.7 

890 

Mutton  chops           

42 

13  5 

28  3 

1,415 

52  9 

15  9 

13  6 

860 

41  8 

13  4 

24  2 

1,245 

Hani    snioked              

34  8 

14  2 

33  4 

1,635 

Bacon      "            .  .          

17  4 

9  1 

62  2 

2,715 

Sausage     Frankfort      

57  2 

19  6 

18  9 

1,155 

Beef  soup          

92.9 

4.4 

0.4 

120 

Chicken    (fowl)           .        

47  1 

13  7 

12.3 

765 

Goose      

38.5 

13.4 

29.8 

1,475 

Turkey       

42  4 

16.1 

18.4 

1,060 

Duck           

51  7 

14  3 

33.4 

1,805 

Squab     ....            .          

58 

18  6 

22.1 

1,430 

Guinea  hen                

69  1 

23  I 

6  5 

870 

Quail                           f  

65  9 

25 

6  8 

935 

When  animals  are  first  slaughtered  the  meat  is  tender  and  juicy, 
but  it  is  seldom  eaten  in  cold  climates,  before  rigor  mortis  has  set 
in,  a  process  which  is  followed  by  a  slow  decomposition,  during  which 
the  meat  becomes  more  tender.  This  process,  which  occurs  when 
meat  is  "hung"  for  a  time,  is  due  to  development  of  lactic  acid, 
which  softens  the  connective  tissue.  The  flavor  of  the  meat  is  at 
the  same  time  enhanced. 

Raw  Meats. —  There  is  a  prevalent  fashion  of  prescribing  raw 
meat,  and  in  some  diseases,  such  as  dysentery  or  chronic  gastritis, 
it  is  useful,  but  it  should  not  be  given  with  the  idea  that  it  pos- 
sesses any  special  curative  virtue  from  the  fact  of  being  raw.  Beef, 
.  mutton,  and  ham  are  all  eaten  in  this  condition.  Meat  is  distaste- 
ful to  most  persons  in  this  state  and  soon  palls  upon  the  appetite, 
and  may  excite  positive  loathing.  There  is  a  natural  aversion  to 
raw  flesh  among  even  the  lowest  tribes  of  man,  who  only  consume 
their  meat  raw  from  excessive  hunger  or  when  fire  is  unobtainable. 


128 

Even  the  primitive  Australian  savage  cooks  his  reptiles  and  worms. 
Eaw  meat  has  no  advantage  either  in  digestibility  or  nutrient  power 
over  moderately  cooked  or  "  underdone  "  meat.  In  fact,  Uffelman, 
experimenting  with  a  boy  having  a  gastric  fistula  found  that  he  di- 
gested raw  scraped  beef  less  quickly  than  roast  beef,  but  Eiibner 
maintains  that  raw  beef  is  more  quickly  but  less  completely  digested 
than  cooked  beef.  Such  discrepancies  of  statement  are  due  to  the  fact 
that  the  difference  in  any  case  is  very  slight,  and  easily  reversed  by 
extraneous  conditions.  See  Digestion  of  Proteids  in  the  Stomach, 
p.  389. 

Some  danger  has  been  attributed  to  eating  raw  meat  on  ac- 
count of  the  possibility  of  acquiring  intestinal  worms  through  it, 
but  the  fear  of  this  is  much  exaggerated. 

On  the  other  hand,  meat  is  easily  altered  and  made  innutritious 
by  prolonged  cooking.  Overdone  meat  is  indigestible  and  tasteless, 
and  if  meat  is  too  long  boiled  it  becomes  insipid  and  useless  as  an 
aliment,  and  the  resulting  soup  is  not  a  full  substitute  for  it. 

Digestibility  of  Meats. —  Among  the  conditions  which  affect  the 
digestibility  and  nutrient  power  of  meats  are  the  age  at  which  the 
animals  eaten  were  killed,  and  the  care  bestowed  upon  them  in  feeding, 
shelter,  and  transportation.  Animals  which  have  been  underfed,  ill- 
treated,  and  worried  yield  very  inferior  meat. 

Almost  all  meat  is  tougher  immediately  after  killing,  and  im- 
proves on  being  kept  for  a  day  or  two.  Meat  should  never  be  cooked 
during  rigor  mortis.  Violent  exercise  is  believed  to  increase  the 
tenderness  of  the  meat  of  hunted  animals. 

In  general,  the  flesh  of  young  is  more  digestible  than  that  of  old 
animals,  provided  they  are  not  still  suckling. 

When  as  much  as  two  pounds  of  roast  beef  are  eaten  daily,  all 
but  3  per  cent  of  its  dry  matter  and  95  per  cent  of  its  fat  is  com- 
pletely digested,  so  that  such  a  heavy  proteid  diet  leaves  very  little 
residue. 

It  would  be  convenient  if  meats  and  animal  foods  of  all  kinds 
could  be  arranged  in  a  table  of  comparative  digestibility,  but  such 
tables  are  necessarily  inaccurate,  if  not  actually  misleading,  owing 
to  the  great  variations  produced  by  the  character  of  the  particular 
samples  of  food  used,  by  the  time  and  manner  of  cooking,  by  the 
condition  of  the  digestive  organs,  and  by  personal  idiosyncrasy.  No 
two  tables  of  this  kind  given  by  different  authors  are  found  to  agree 
in  all  respects. 

There  are  several  reasons  for  such  discrepancy.  In  the  first 
place  the  alimentary  canal  is  not  a  test  tube  and  laboratory  experi- 


ANIMAL  FOODS 


129 


ments  cannot  be  made  to  reproduce  in  all  respects  the  phenomena  of 
digestion.  Secondly,  the  disagreeable  act  of  passing  a  stomach  tube 
in  man  to  determine  food  residues  after  ingestion  of  a  meal  may  itself 
inhibit  digestion  through  anticipation.  Thirdly,  there  is  much  truth 
in  that  "  digestion  waits  on  appetite,"  and  the  person  who  dislikes 
salt  pork,  yet  is  made  to  eat  it  in  a  digestion  experiment  is  far  less 
likely  to  completely  digest  it  than  one  who  is  fond  of  it.  At  one 
time  a  person  may  digest  certain  foods  completely,  and  promptly, 
which  at  another,  from  trivial  causes,  entirely  fail  of  digestion. 
Fourthly,  there  is  marked  difference  between  prompt  and  complete 
digestion.  Of  two  persons  in  health  one  may  digest  a  given  food 
very  promptly  and  another  require  half  an  hour  or  an  hour  longer, 
yet  in  both  the  process  may  be  ultimately  complete.  Finally  in  some 
persons  stomach  digestion  is  relatively  more  complete  than  in  others, 
in  whom  a  major  part  of  the  process  takes  place  in  the  intestine, 
but  of  course  food  residue  experimentally  withdrawn  during  diges- 
tion, by  means  of  the  stomach  tube,  can  only  represent  the  gastric 
phase  of  the  process. 

For  these  reasons  the  following  tables  are  not  to  be  regarded  as 
in  any  sense  infallible,  but  merely  as  affording  a  general  guide  to 
which  there  must  be  many  exceptions.  (See  Duration  of  Digestion 
in  the  Stomach. 

Table  of  Comparative  Digestibility    (commencing  with   the  Most  Digestible, 
and  ending  urith  the  Least  Digestible  Common  Animal  Foods). 


Oysters. 

Eggs,  soft-cooked,  scrambled  or 
omelette. 

Sweetbread. 

Some  fish,  boiled  or  broiled,  such 
as  white  fish,  shad,  red  snap- 
per, weakfish,  smelt. 

Chicken,  boiled  or  broiled. 

Lean  roast  beef  or  beefsteak. 

Mutton,  roasted  or  boiled,  chops. 

Squab,  partridge,  quail. 

Bacon   (crisp),  lean  ham. 

Roast  fowl,  chicken,  capon,  tur- 
key. 


Roast  lamb. 

Young    venison. 

Liver. 

Corned  beef. 

Veal. 

Salmon,  mackerel,  herring,  blue- 
fish. 

Duck,  goose,  and  game. 

Lobsters  and  crabs. 

Pork. 

Smoked,  dried,  potted  or  pickled 
fish  and  meats  in  general. 


The  table  given  below  is  published  by  E.  Jessen  as  the  result  of 
giving  test  meals  of  single  meats.  The  stomach  was  first  cleansed 
and  emptied  by  siphonage,  then  a  hundred  grains  of  meat  were 
introduced  with  eight  ounces  of  water.  Samples  of  the  digested 
stomach  contents  were  from  time  to  time  withdrawn,  and  the  com- 
plete disappearance  of  all  muscular  fiber  when  examined  by  the  mi- 
croscope occurred  as  follows : 
11 


130          FOODS  AND  FOOD  PREPARATIONS 

Beef,   raw,   chopped   fine    2     hours. 

Beef,   half  cooked    2% 

Beef,   well   cooked    3 

Beef,   thoroughly   roasted 4 

Mutton,  raw   2 

Veal,    cooked    2% 

Pork,    cooked    3 

These  estimates  fall  somewhat  below  those  of  other  writers,  and 
for  comparison  Jessen  gives  the  time  for  digestion  of  six  hundred  cubic 
centimeters  of  raw  cow's  and  goat's  milk  as  three  and  a  half  hours, 
and  that  of  boiled  milk  as  four  hours,  which  is  too  long. 

H.  S.  Grindley  states  as  a  result  of  99  digestion  experiments  on 
man  (TJ.  S.  Dept.  Agriculture,  Bui.  No.  193)  that  red  beef 
is  not  less  digestible  than  fresh  pork,  nor  do  the  different  cuts  of 
meats  vary  in  digestibility.  He  found  that  80  per  cent  of  meat  pro- 
tein is  digested  within  an  hour,  and  90  per  cent  within  two  hours, 
whatever  the  variety  of  meat,  or  method  of  cooking.  This  is  an 
average,  but  individuals  presented  variations  and  contradictory  re- 
sults at  times,  as  compared  with  each  other.  As  an  average  result 
of  44  other  experiments  with  different  kinds  of  meats  ingested  98 
per  cent  of  protein  and  98  per  cent  of  fat  was  digested,  and  dif- 
ferences in  the  meat  itself  or  in  its  cooking,  were  "  too  small  to  reckon," 
fat  meat  being  as  well  digested  as  lean. 

Gigglberger  found,  as  a  result  of  feeding  patients  with  test  meals 
and  withdrawing  the  stomach  contents  through  a  tube,  that  meat 
requires  from  two  and  a  half  to  five  and  a  half  hours  for  gastric 
digestion,  according  to  its  quality,  method  of  cooking,  etc.  Stewed 
meats  need  less  than  roasts.  Pork  and  very  fat  meat  may  require 
four  or  five  or  more  hours,  and  veal  needs  at  least  four  hours.  Fresh 
lamb  may  be  digested  in  two  and  a  half  to  three  hours.  Chicken, 
capon  and  turkey  may  be  digested  in  from  two  to  two  and  a  half  hours, 
but  the  meat  of  many  wild  birds,  such  as  ducks,  may  require  four 
hours.  These  are  longer  periods  than  other  authors  give. 

Composition  of  Beef. —  The  composition  of  beef  varies  with  the  * 
feeding  of  the  animal.  A  young  steer  from  two  and  a  half  to 
five  years  old  furnishes  the  best  meat.  If  the  animal  is  lean  the 
meat  may  yield  from  70  to  75  per  cent  of  water  and  about  20  per  cent 
of  nitrogenous  material,  furnishing  about  415  calories  per  pound, 
with  2  or  3  per  cent  of  fat ;  but  if  very  fat  when  killed,  the  percentage 
of  both  water  and  nitrogenous  material  is  considerably  reduced, 
while  that  of  the  fat  may  be  as  high  as  25  per  cent,  or  more.  As  a 
general  average,  one-third  of  beef  is  nutritious  material,  the  remainder 
is  water  and  bone. 


ANIMAL  FOODS  131 

Beef  fat  is  composed  of  glycerides  of  fatty  acids.  It  melts  at  from 
106°  to  122°  F.  Stearic  and  palmitic  acids  are  present  in  the  propor- 
tion of  three  to  one  of  oleic  acid. 

The  equivalent  of  beef  is  sometimes  stated  in  terms  of  other  foods. 
A  pound  of  lean  beef  is  believed  to  equal  in  nutrient  value  two  and  a 
half  pints  of  milk,  half  a  pound  of  bread,  and  about  three  eggs,  but 
these  are  only  approximate  figures.  Lean  beef  on  an  average  contains 
4  to  5  times  the  percentage  of  protein  found  in  milk,  and  beef  con- 
tains less  protein  than  game  birds  and  more  than  fish. 

Fresh  beef  may  be  eaten  longer  continuously  than  any  other  kind 
of  meat.  In  this  respect  it  resembles  bread  and  rice.  Attempts 
have  sometimes  been  made  on  wagers  to  eat  quail  or  partridge  three 
times  a  day  consecutively  for  a  month,  but  disgust  is  sure  to  follow 
after  a  week  or  two,  no  matter  how  much  such  food  is  varied  in  the 
cooking,  and  by  the  end  of  a  month  it  may  excite  extreme  loathing, 
and  even  nausea  and  vomiting. 

Chipped  beef  is  prepared,  like  corned  beef,  by  pickling  for  a  month,' 
when  it  is  smoked  for  two  days  and  dried  for  a  fortnight,  after  which 
it  is  sliced  thin  by  machinery  and  is  ready  for  packing. 

BEEF  PREPARATIONS    FOR  THE  SICK 

Beef  is  so  important  a  food  for  well  and  sick  alike  that  many  at- 
tempts have  been  made  to  improve  its  digestibility  for  the  latter. 

Most  of  these  efforts  are  aimed  at  concentrating  the  meat  by  re- 
moving all  indigestible  connective-tissue  fiber,  the  muscle  sheaths, 
sarcolemma,  and  blood  vessels. 

In  some  cases  the  process  of  concentration  is  carried  still  further 
and  water  is  driven  off  by  evaporation,  or  some  of  the  active  prin- 
ciples of  the  meat  are  extracted  and  condensed.  Sometimes  the  meat 
is  predigested.  Different  meats  may  be  prepared  in  these  ways,  but 
the  best  lean  beef  free  from  coarse  fiber  is  usually  preferred. 

It  was  long  ago  shown  by  Schiff  that  many  fluid  substances,  such 
as  meat  extract,  soups,  peptones,  and  even  vegetable  purees  when 
taken  at  the  commencement  of  a  meal,  on  being  absorbed  into  the 
blood,  favor  the  flow  of  gastric  juice.  This  is  true  also  of  peptones 
injected  into  the  rectum,  so  the  effect  is  not  wholly  due  to  local  stim- 
ulation of  the  inner  surface  of  the  stomach. 

Much  attention  of  late  has  been  given  to  the  predigestion  of  meat, 
and  especially  to  the  production  of  albumoses,  which  are  more  soluble 
and  assimilable  than  undigested  meat  albumin,  and  which  are  said  to 
possess  greater  nutritive  property  than  peptones. 


132          FOODS  AND  FOOD  PREPARATIONS 

The  beef  extracts  made  in  this  country  usually  have  a  less  disagree- 
able taste  and  odor,  and  are  lighter  in  color  than  those  made  of  South 
or  Central  American  beef. 

In  general,  about  three  grams  (46  grains)  of  meat  extract  consti- 
tute a  good  soup  ration,  and  such  preparations  are  often  valuable  for 
addition  to  invalid  soups  and  broths  when  thickened  with  eggs,  rice, 
sago,  pearl  barley,  macaroni,  ground  toast,  etc. 

It  is  not  desirable  to  rely  for  long  upon  any  artificial  meat  prepara- 
tions, for  they  are  costly,  are  soon  tired  of  by  the  patient,  and  many 
of  the  fluid  ones  contain  considerable  alcohol.  As  a  rule  fresh  beef 
juice  or  home-made  bouillon  or  broths  are  sufficiently  digestible  to 
meet  all  requirements  and  I  am  inclined  to  agree  with  Hutchinson, 
who  says  of  meat  extracts,  "  Their  proper  place  is  in  the  kitchen,  not 
by  the  bedside/'  Nevertheless  their  use  is  so  general  that  a  few  of  the 
typical  ones,  from  an  almost  innumerable  list,  will  be  described  below. 

The  preparations  of  meat  for  the  sick  are  both  (1)  solid  and 
(2)  fluid. 

(1)  Solid  Meat  Preparations. —  Scraped  meat  is  made  best  from 
tender  beefsteak,  broiled  for  a  few  minutes  over  a  brisk  fire,  but  rare 
roast  beef  or  mutton  chops  may  be  used.  With  a  dull  knife  or  an  iron 
spoon  the  pulp  is  scraped  out.  The  indigestible  and  less  nutritious 
connective-tissue  sheaths  of  the  muscle  fasciculi  are  broken  and  left 
behind,  while  the  fibers  themselves  (or  their  myosin)  are  obtained 
in  the  form  of  a  soft  unirritating  mass  which  readily  is  acted  upon 
by  the  gastric  juice.  The  pulp  may  be  run  through  a  sieve.  It  is 
then  salted,  and  may  be  made  into  little  balls  and  browned  just  be- 
fore eating.  This  is  done  by  placing  the  balls  on  a  hot  frying  pan, 
which  is  not  greasy,  and  turning  them  over  so  that  the  outside  be- 
comes well  seared.  They  should  then  be  set  aside  on  a  cooler  part 
of  the  stove  or  oven  and  allowed  to  remain  until  the  raw  red  color 
of  the  interior  turns  slightly  to  drab. 

Some  patients  prefer  to  eat  the  scraped  meat  raw  or  lightly  cooked, 
spread  as  a  sandwich  between  thin  slices  of  bread  and  butter.  This 
meat  may  be  fed  to  infants  in  their  second  year,  and  the  meat  balls  and 
sandwiches  are  invaluable  in  the  treatment  of  chronic  gastritis,  dila- 
tation of  the  stomach,  typhoid  convalescence,  and  other  affections. 

Moxquera's  beef  meal  is  made  by  digesting  fresh  tender  lean  beef 
witli  pineapple  juice  until  the  muscle  fiber  is  almost  completely  con- 
verted into  peptones.  After  digestion  the  preparation  is  desiccated. 
Chittendcn's  analysis  of  this  meal  shows  it  to  contain  90  per  cent  of 
nutriment,  13  per  cent  of  which  is  fat  and  77  per  cent  is  protein.  Of 
the  latter,  almost  half  consists  of  albumoses  and  peptones  fit  for 


ANIMAL  FOODS  133 

prompt  absorption.  The  remaining  portion  is  believed  to  be  in  a 
condition  in  which  it  is  more  digestible  than  plain  meat.  The  beef 
meal  is  tasteless  and  odorless,  which  are  decided  advantages,  as  it  can 
be  flavored  according  to  preference.  It  should  be  salted,  and  may  be 
added  to  broths  and  soups.  It  may  be  used  with  equal  parts  of  sugar 
and  cocoa,  and  added  to  hot  milk. 

Mosquera's  beef  jelly  is  made  in  a  similar  manner,  but  is  evaporated 
to  the  consistence  of  a  solid  extract.  Analyzed  by  Ludwig,  it  was 
found  to  contain  only  3  per  cent  of  insoluble  material,  and  of  the 
soluble  portion  53  per  cent  consists  of  albuminoids  which  are  nearly 
all  peptones.  It  is  of  pleasant  taste  and  odor,  and  is  highly  nutri- 
tious. Dissolved  in  boiling  water,  it  may  be  given  alone  with  a  pinch 
of  salt  or  added  to  reinforce  any  broth,  gruel,  consomme,  beaten 
eggs,  or  milk.  The  beef  jelly  is  even  more  digestible  than  the  meal. 
It  is  sometimes  combined  with  cocoa. 

The  beef  meal  and  jelly  are  both  excellent  for  use  in  gastritis, 
gastric  catarrh,  ulcer,  and  carcinoma,  and  many  forms  of  enfeebled 
assimilation. 

Benger's  peptonized  beef  jelly  is  another  good  beef  preparation 
much  in  vogue  in  England  for  the  same  purposes  as  Mosquera's 
preparations.  It  may  be  taken  cold  or  dissolved  in  hot  water  as  a 
concentrated  beef  tea,  representing  a  large  amount  of  meat  fiber.  It 
is  a  useful  stimulant  for  the  aged  who  have  feeble  digestive  power. 
It  may  be  given  to  them  in  teaspoonful  doses. 

Tropon  is  a  condensed  proteid  preparation  of  granular  consist- 
ence, said  to  contain  89  per  cent  of  protein  (Kleine).  It  is  tasteless, 
insoluble,  and  may  be  added  to  milk,  broth,  rice,  or  other  food,  and 
several  drachms  may  be  given  daily. 

Darby's  fluid  meat  is  a  moist  extract  which  has  a  strong  meaty 
taste.  It  may  be  eaten  spread  on  thin  bread  and  butter  or  cracker, 
or  it  may  be  dissolved  in  hot  water. 

Powdered  beef  is  made  as  follows : 

Chop  lean  beef  into  small  pieces,  dry  on  a  water-bath  or  in  an 
oven  with  a  slow  fire,  and  powder  in  a  coffee  mill  or  with  a  machine 
constructed  for  the  purpose.  Do  not  over-dry.  This  powder  may  be 
mixed  with  hot  water  or  any  form  of  soup,  milk,  chocolate,  grog,  or 
punch.  In  process  of  drying,  which  occupies  from  five  to  twenty- 
four  hours,  the  meat  loses  rather  more  than  four-fifths  of  its  weight. 

Dujardin-Beaumetz's  "  grog  de  la  poudre  de  viande  "  is  prepared 
as  follows:  Take  two  tablespoonfuls  of  meat  powder,  three  dessert- 
spoonfuls of  essence  or  sirup  of  rum  punch,  and  add  milk  enough  to 
make  quite  fluid.  In  this  way  he  claims  that  the  equivalent  of  three 


134          FOODS  AND  FOOD  PREPARATIONS 

and  a  half  pounds  of  meat  may  be  given  daily.  He  strongly  recom- 
mends powdered  meat  for  forced  alimentation  (see  Suralimentation  in 
Phthisis). 

Professor  Finkler,  of  Bonn,  has  made  a  proteid  food  which  he 
claims  — "  1.  Has  the  greatest  amount  of  albumin  possible  up  to 
90  per  cent.  2.  Is  digestible  up  to  almost  its  entire  weight.  3.  Can 
be  made  equal  in  amount  for  each  day.  4.  Keeps  well  indefinitely  in 
all  climates.  5.  Its  flavor  and  taste  do  not  interfere  with  that  of  other 
food.  6.  Its  price  is  the  lowest  possible." 

This  food  consists  of  the  nitrogenous  parts  of  meat,  fish,  and 
legumes.  It  is  odorless,  tasteless,  and  forms  a  light  yellow  granular 
powder.  Kb'nig's  anaylsis  of  this  food  follows:  Protein,  89.87  per 
cent.  Water,  8.89  per  cent.  Ash,  1.24  per  cent.  Fat,  0.20  per  cent. 

Beef  Blood. —  Dried  beef  blood,  powdered,  has  been  recommended 
by  Regnard  and  others  for  use  by  addition  to  soups  and  various 
forms  of  foods.  The  taste  and  odor  of  dried  blood  is  disagreeable, 
and  the  idea  of  eating  it  in  any  form  is  repugnant  to  most  persons. 

It  has  also  been  used  for  rectal  injection,  but  I  have  always  ob- 
served it  to  cake  inside  the  rectum,  and  there  is  very  little  evidence 
that  it  is  absorbed  there  at  all. 

Meat  lozenges  are  prepared  by  Mason  as  a  convenient  and  port- 
able form  of  condensed  food.  Soup  lozenges  and  capsules  are  also 
made. 

*Bcef  peptonoids  are  prepared  in  powdered  form  by  several  manu- 
facturers; one  variety  contains  predigested  and  sterilized  beef,  milk, 
and  gluten. 

Rudiscli's  Iccf  peptone  (or  sarcopeptone)  is  a  dark-brown,  semi- 
solid  paste,  having  a  strong  meaty  odor  and  flavor.  One  pound 
of  this  preparation  represents  eight  pounds  of  fresh  lean  beef.  In 
addition  to  the  extractive  materials  which  are  obtainable  in  ordinary 
beef  tea,  it  contains  predigested  proteids  in  a  form  suited  for  prompt 
absorption.  It  may  be  eaten  spread  upon  crackers  or  toast,  or  it 
may  be  dissolved  in  chocolate  or  almost  any  suitable  fluid,  either 
hot  or  cold.  It  is  given  in  doses  varying  from  half  a  teaspoonful 
or  less  for  young  children,  up  to  a  teaspoonful  or  tablespoonful  for 
adults.  If  its  flavor  when  dissolved  in  water  alone  is  disagreeable 
or  becomes  tiresome,  it  may  be  altered  by  giving  it  ice  cold,  or  by 
the  addition  of  salt,  celery-salt,  pepper,  or  "Worcestershire  sauce,  and 
for  children  it  may  lie  sweetened  with  sugar.  It  is  often  added  to 
milk,  sherry,  eggnog,  gluten,  and  farinaceous  gruels  of  oatmeal,  rice, 
or  arrowroot,  or  it  may  be  used  to  reinforce  soups,  broths,  and 
jellies. 


ANIMAL  FOODS  135 

The  Maltine  Company  furnish  a  similar  preparation  which  con- 
tains 70  per  cent  of  albuminous  material  with  phosphates,  fat,  and 
carbohydrates. 

The  South  American  Beef  Extract  is  a  predigested  preparation 
which,  by  the  analysis  of  Kemmerich,  contains,  with  other  proteid 
matter,  a  large  proportion  —  over  27  per  cent  —  of  albumoses  and 
peptones,  ready  for  immediate  absorption. 

Somatose  is  a  granular  predigested  meat  powder  which,  accord- 
ing to  analysis  reported  by  Hildebrandt,  contains  90  per  cent  of 
deutero-  and  hetero-albumose,  and  is  free  from  peptones.  It  is  of 
a  yellowish  color,  amorphous,  finely  granular,  having  faint  taste 
and  odor.  Dissolved  in  water,  it  forms  a  clear,  light  yellow  or 
brownish  solution,  almost  tasteless.  It  is  not  precipitated  by  heat 
or  by  strong  acids.  The  latter,  in  fact,  redissolve  a  precipitate 
which  is  formed  by  very  weak  acids.  It  is  claimed  for  it  that  it  is 
eight  times  as  nutritious  as  meat,  but  estimates  of  this  kind  applied 
to  artificial  foods  are  always  fallacious.  Of  course  for  an  invalid 
who  cannot  digest  any  meat  such  preparations  are  indefinitely 
"  stronger,"  but  for  those  who  can  assimilate  meat  they  are  much 
weaker.  Somatose  may  be  injected  in  hypodermic  solution  without 
local  irritation.  It  may  be  given  as  fine  powder  with  bread  and 
butter  or  spread  upon  toast.  It  is  also  administered  like  similar 
preparations  in  milk,  mucilage,  soup,  cocoa,  or  coffee.  When  mixed 
with  such  substances  it  should  be  stirred  first  into  a  thin  paste  with 
an  equal  volume  of  the  fluid  and  then  added  to  the  remainder. 

It  is  well  tolerated  by  irritable  stomachs  and  is  speedily  absorbed, 
and  it  possesses  -the  advantage  of  having  a  less  disagreeble  taste 
than  many  preparations  of  meat. 

Essay's  Food  is  an  albuminized  food  suitable  for  emergency  feed- 
ing of  infants  and  for  adults  with  disordered  stomach  or  bowels. 

Sanatogen  is  a  nearly  tasteless,  odorless  meat  preparation  espe- 
cially endorsed  by  Prof.  Karl  E.  Ewald  of  Berlin.  It  contains  casein 
with  5  per  cent  of  glycerophosphate  of  sodium.  It  may  be  added  to 
soup,  milk,  cocoa,  broths,  or  gruels,  etc. 

(2)  Fluid  Meat  Preparations. —  Beef  juice  contains  serum,  lymph, 
and  blood. 

H.  P.  Loomis  gave  the  following  useful  details  in  regard  to  the 
preparation  of  this  important  food :  "  To  obtain  from  the  meat 
the  maximum  amount  of  juice,  a  meat  squeezer  is  absolutely  essen- 
tial. There  are  a  number  of  good  ones  in  the  market,  which  range 
in  price  from  one  to  three  dollars.  The  best  kind  of  meat  from 
to  squeeze  the  juice  is  a  thick  round  steak  free  from  fat. 


136          FOODS  AND  FOOD  PREPARATIONS 

This  should  be  seasoned  with  pepper  and  salt,  broiled  over  a  brisk 
fire,  cut  in  pieces  two  inches  square,  and  then  put  into  the  meat 
squeezer.  About  eight  ounces  of  juice  can  be  obtained  from  each 
pound  of  meat.  No  further  direct  heat  should  be  applied  to  the 
juice,  as  the  albumin  would  be  at  once  coagulated  and  the  juice 
rendered  worse  than  useless.  If  the  juice  becomes  cold  and  it  is 
advisable  to  heat  it,  this  can  be  best  accomplished  by  placing  the  cup 
in  hot  water.  Freshly  squeezed  beef  juice  is  the  best  of  the  artificial 
preparations  of  meat  known,  and  the  trouble  of  preparing  it  is  well 
repaid  by  the  marked  improvement  in  the  patient." 

When  beef  is  chopped  and  squeezed  under  great  pressure,  juice 
is  obtained  from  it  in  the  proportion  of  23  per  cent,  but  only  about  6 
per  cent  is  albumin  (Bauer). 

Fresh  beef  juice  is  serviceable  for  feeding  in  many  cases  of  severe 
gastric  disturbance  with  vomiting  and  pain;  also  in  typhoid  fever, 
and  for  feeding  infants  at  the  end  of  the  first  and  in  the  second  year. 
From  one  to  three  tablespoonfuls  may  be  given  at  once,  and  it  forms 
a  good  introduction  for  the  stomach  to  solid  food.  It  is  usually  much 
to  be  preferred  to  any  of  the  foregoing  extracts  and  other  prepara- 
tions. If  desired,  it  may  be  paftcreatinized  like  milk  (see  Pancreat- 
inizcd  Milk,  p.  90). 

Beef  Tea. —  The  nutritive  value  of  beef  tea  has  formed  a  sub- 
ject for  much  discussion.  The  assertion  often  is  made  that  it  is  a 
comparatively  useless  preparation,  and  it  is  said  that  a  pint  of  it  con- 
tains "  scarcely  a  quarter  of  an  ounce  of  anything."  Hassell  estimates 
that  fourteen  pounds  and  a  half  of  beef  would  be  required  to  make 
enough  tea  to  counterbalance  the  daily  nitrogenous  waste  of  one  man. 
If  rightly  made,  however,  it  may  be  nutritious,  although  the  quan- 
tity of  proteid  which  can  be  dissolved  in  it  at  any  time  is  much  less 
than  exists  in  a  similar  volume  of  milk  or  an  egg.  Its  preparation 
should  be  conducted  as  follows:  Tender  lean  raw  beef  is  chopped 
into  small  pieces  about  a  quarter  of  an  inch  in  diameter  and  macerated 
in  cold  water  for  five  or  six  hours.  The  water  is  to  be  added  in  the 
proportion  of  a  pint  to  a  pound  of  lean  beef;  ten  drops  of  hydro- 
chloric acid  are  then  added,  and  the  solution  is  gradually  heated  to 
160°  F.,  but  not  more,  for  from  fifteen  to  thirty  minutes.  This  is 
best  accomplished  by  placing  the  vessel  in  a  larger  outer  vessel  of 
boiling  water.  Various  forms  of  water-baths,  which  the  French  call 
"  bain  marie "  or  milk  scalders,  are  sold,  which  are  conveniently 
adapted  for  the  process  of  making  beef  tea. 

The  prolonged  soaking  of  meat  in  cold  water  dissolves  its  mineral 
ingredients  —  chiefly  chloride  and  sulphate  of  potassium,  and  also 


ANIMAL  FOODS  137 

extractives,  principally  creatin  and  creatinin  and  some  lactid  acid 
derived  from  the  muscle  fibers.  There  also  may  be  a  little  albumin 
present,  but  the  albumin  of  meat  or  muscle  is  very  sparingly  soluble 
in  simple  aqueous  solutions,  and  hence  it  does  not  diffuse  readily 
into  the  water,  but  the  addition  of  hydrochloric  acid  converts  the  in- 
soluble myosin  into  an  acid  albumin  called  syntonin,  which  is  soluble. 

In  making  beef  tea,  more  or  less  fat  is  derived  from  the  meat, 
which  floats  upon  the  surface  and  presents  a  very  unappetizing 
appearance.  This  should  always  be  skimmed  or  strained,  and  if  it 
collects  on  cooling,  the  operation  may  be  repeated.  A  crust  of  bread 
dipped  beneath  the  surface  will  remove  the  supernatant  layer  of  fat. 

It  is  always  desirable  to  give  special  attention  to  the  proper  fla- 
voring of  food  for  fever  patients.  In  cases  where  a  fluid  diet  is 
necessitated  for  many  days  in  succession,  much  depends  upon  the 
willingness  of  the  patient  to  take  the  food  offered  him,  and  a  dread 
of  too  frequently  recurring  intervals  of  feeding  with  the  positive 
dislike  which  the  monotonous  taste  of  certain  meat  preparations 
begets,  reacts  unfavorably  upon  the  digestion.  It  is  advisable  to  con- 
sult the  individual  taste  of  patients  in  this  regard,  and  when  they 
positively  assert  that  they  cannot  take  beef  tea  or  bouillon  or  meat 
extracts  in  any  form,  their  opposition  often  may  be  overcome  by 
adding  the  expressed  juice  of  some  fresh  vegetables  of  which  they 
are  fond.  Carrots,  celery,  parsnips,  and  endives  may  be  boiled  alone 
or  with  an  aromatic  herb,  such  as  parsley  or  green  mint,  and  after- 
wards chopped  fine  and  their  juice  expressed  by  squeezing  them  in  a 
muslin  bag.  Such  juices  added  to  beef  tea  and  broth  impart  an 
altogether  different  flavor,  which  may  be  varied  from  time  to  time 
by  changing  the  vegetables  (Yeo). 

The  total  quantity  of  albuminous  material  which  may  be  obtained 
in  the  manner  above  described  in  a  reasonable  bulk  of  fluid  is  very 
little,  but  in  febrile  conditions  it  is  usually  good  for  the  patient  to 
ingest  abundant  water,  and  there  is  no  objection  to  part  of  the  fluid 
being  taken  in  the  form  of  beef  tea.  On  the  other  hand,  if  patients 
have  absolute  anorexia  they  are  soon  wearied  by  the  effort  of  swal- 
lowing, and  it  is  preferable  to  give  proteids  in  more  concentrated 
form. 

Beef  tea  may  be  given  with  beaten  eggs,  or  gelatin  may  be  put  in 
to  stiffen  the  mass  into  a  jelly,  which,  when  properly  seasoned,  is 
palatable.  It  also  may  be  thickened  with  broken  crackers,  and 
with  the  addition  of  a  little  butter,  pepper,  and  salt,  it  becomes  much 
more  nutritious ;  or  sago,  arrowroot,  or  chocolate  may  be  mixed  with  it. 

Bouillon,  or  the  French  pot  au  feu,  is  of  little  more  value  as  an  ali- 
12 


138          FOODS  AND  FOOD  PREPARATIONS 

ment  or  heat  producer  than  beef  tea  or  extractum  carnis.  It  is  a 
good  vehicle  for  giving  beaten  or  dropped  eggs,  flour,  etc.  It  stim- 
ulates the  nerves,  but  in  a  much  less  degree  than  alcohol.  It  has  the 
advantage  over  the  latter  and  over  condiments  that  it  is  never  poi- 
sonous. A  good  meat  puree  may  be  made  by  adding  a  tablespoon- 
ful  of  scraped  beef  to  three  or  four  tablespoonfuls  of  bouillon,  warm- 
ing over  a  brisk  fire  until  the  meat  turns  of  a  faint  drab  color,  and 
seasoning  with  pepper,  and  salt  or  a  little  butter. 

Beef  broth  is  agreeable  to  invalids,  but  on  the  whole  it  is  less  nu- 
tritive than  that  made  from  chicken,  veal,  or  mutton.  As  ordinarily 
made,  it  contains,  besides  salts  and  extractives,  %  per  cent  each  of 
fat  and  albumin  and  1  per  cent  of  gelatin. 

Meat  Extracts,  etc. —  Under  this  title  are  classed  a  variety  of  arti- 
ficial meat  preparations  both  solid  and  fluid,  the  term  being  a  very 
general  one.  There  are  three  main  classes,  viz.:  (1)  True  extracts 
containing  the  salts  and  flavoring  material  of  meat,  and  little  else. 
(2)  Meat  juice  expressed  and  preserved  with  alcohol  or  otherwise, 
containing  more  or  less  protein.  (3)  Albumose  or  peptose  prepara- 
tions, consisting  of  soluble  products  of  artificial  digestion  of  meat. 
For  the  most  part  beef  is  used  for  all  the  meat  "  extracts,"  but  other 
kinds  of  meat  may  be  employed. 

Liebig's  extract  of  meat,  or  "  extractum  carnis,"  consists  of  fla- 
voring extractive  matters  such  as  creatin,  isolin,  decomposable  hre- 
matin,  and  salts.  Some  of  these  substances  are  excrementitious, 
and  on  this  account  Masterman  compares  it  to  urine,  although  it 
contains  less  urea. 

A  pound  of  mutton  is  represented  by  two-fifths  of  an  ounce  of 
the  extract.  It  contains  no  albumin  or  fibrin,  and  has  in  all  only  2 
per  cent  of  solids,  hence  its  nutritive  power  is  practically  nil,  but  when 
regarded  as  a  stimulant  and  so  used,  it  removes  fatigue,  strengthens 
the  action  of  the  heart  and  nervous  system,  improves  the  func- 
tional activity  of  the  stomach,  and  in  this  manner  aids  the  digestion 
of  foods.  There  is  no  occasion  for  taking  it  in  large  quantities,  and 
when  this  has  been  done,  symptoms  of  slight  ptomaine  poisoning 
have  been  observed,  such  as  heaviness  and  stupor  (Yeo). 

Valentine's  meat  juice  is  a  clear  fluid  of  a  deep  claret-color,  hav- 
ing a  meaty  odor  and  strong  meaty  taste.  It  is  prescribed  in  doses 
of  one-half  to  two  teaspoonfnls,  diluted  in  eight  times  its  bulk  of 
cold  water,  or  it  may  be  mixed  with  cracked  ice.  Its  taste,  which  is 
disagreeable  to  many  patients,  is  easily  disguised  by  the  addition  of 
half  a  tumblerful  of  milk,  or  it  may  be  mixed  with  light,  farinaceous 
gruels  (after  they  have  cooled  to  130°  F.),  or  used  to  reinforce  soups 


ANIMAL  FOODS  139 

and  broths  or  cod-liver  oil.  Like  Liebig's  extract,  it  may  be  given 
by  the  rectum.  An  ounce  of  this  preparation  is  said  to  represent 
the  concentrated  pure  juice  of  two  pounds  of  the  best  lean  beef  or 
the  condensed  essence  of  three-fourths  of  a  pint  of  natural  expressed 
beef  juice.  Among  other  ingredients  it  contains  haemoglobin  and 
some  albumin.  It  keeps  well  in  all  climates  when  tightly  corked. 
It  should  not  be  diluted  with  hot  water,  strong  liquors,  or  acid  medi- 
cines, as  these  substances  alter  it  and  lessen  its  value.  It  may  be 
given  in  wine  and  in  tea  which  is  not  too  hot. 

Bovinine  is  the  concentrated  expressed  juice  of  raw  lean  beef  ob- 
tained without  use  of  heat  or  acid.  It  is  claimed  that  each  ounce 
represents  nearly  one  pound  of  beef,  that  it  contains  26  per  cent 
of  coagulable  albumin,  and  that  it  keeps  well  without  decomposition 
owing  to  the  addition  of  glycerin  and  alcohol.  It  is  said  to  contain 
egg  albumen  also.  It  may  be  given  per  os  in  doses  of  a  teaspoonful 
or  more,  or  in  ounce  doses  with  pancreatin  for  rectal  injection.  Not 
being  predigested,  it  may  be  pancreatinized  like  milk. 

Beef  Peptones. —  There  are  innumerable  fluid  preparations  of  pep- 
tonized  beef  which  may  be  employed  to  tide  over  an  emergency  after 
a  severe  operation  or  collapse  from  hemorrhage,  uncontrollable  emesis, 
etc. 

All  the  products  of  pancreatin  digestion,  as  well  as  the  ferment 
derived  from  the  juice  itself,  decompose  if  exposed  for  any  length  of 
time  to  the  air. 

The  use  of  peptones  for  invalid  foods  is  open  to  the  objection  that 
after  a  short  time  they  excite  disgust,  owing  to  their  disagreeable 
strong  meaty  odor  and  bitter  taste,  and  may  cause  vomiting  and 
diarrhoea.  The  more  complete  the  conversion  of  albumin  into  pep- 
tone the  more  bitter  it  becomes. 

This  difficulty  is  overcome  when  peptones  are  used  for  rectal  injec- 
tion. Efforts  are  made  to  disguise  the  disagreeable  taste  and  odor  of 
beef  peptones  in  various  ways.  When  obtained  in  solution,  wines 
and  aromatic  substances  are  added  to  them  or  they  are  sometimes  evap- 
orated to  dryness,  pulverized,  and  redissolved  in  sherry,  but  the  taste 
is  exceedingly  persistent  and  it  is  often  difficult  or  impossible  to  dis- 
guise it  in  any  manner,  so  that  patients  will  not  sooner  or  later 
object  to  it.  Among  the  principal  peptones  which  are  used  are  Carn- 
rick's,  Savory  and  Moore's,  and  Benger's.  Some  of  the  pancreat- 
inized foods  are  strengthened  by  addition  of  predigested  starches  and 
sugars.  They  constitute  good  temporary  foods  for  cases  of  enfee- 
bled digestion  or  diminished  absorptive  power. 

Pure  meat  peptones,  prepared  either  by  pepsin  and  hydrochloric 


140          FOODS  AND  POOD  PREPAEATIONS 

acid  or  by  trypsin  in  alkaline  solution,  are  ready  for  immediate  ab- 
sorption, but  Voit,  Politzer,  Gerlach,  and  others  maintain  that  true 
peptone  possesses  little  if  any  nutritive  power,  and  that  the  albu- 
moses  are  directly  absorbed  from  the  alimentary  canal  without  con- 
version into  peptones. 

Bread-and-beef  peptone,  or  "  panopeptone,"  is  a  preparation  in 
which  wheat  starch  and  beef  are  both  predigested  and  preserved  in 
sound  sherry  (over  20  per  cent  by  volume).  It  may  be  taken  cold  in 
doses  of  one  to  four  teaspoonfuls  iced,  or  with  carbonic-acid  water, 
or  wines,  but  it  should  not  be  mixed  with  milk  or  other  foods.  Beef 
peptonoids  also  are  mixed  with  predigested  milk  and  gluten. 

All  peptonized  or  pancreatinized  foods  are  open  to  the  objection 
that  they  are  much  more  expensive  if  used  for  a  long  time  than  the 
preparations  which  easily  may  be  made  at  the  bedside  by  any  intel- 
ligent person  by  the  use  of  the  simple  pancreatin  extracts.  Among 
these  extracts  are  Benger's  Liquor  Pancreaticus  and  Peptonizing 
Powders  and  Fairchild's  Zymine,  which  act  upon  lean  meat  as  well 
as  milk.  If  complete  peptonization  is  required,  large  quantities  of 
the  ferment  must  be  used,  and  the  process  should  be  continued  longer 
than  for  a  less  degree  of  peptonization. 

Summary. —  Most  of  these  preparations  are  given  in  doses  of  one 
or  two  tablespoonfuls  once  in  four  hours.  Usually  they  are  tired 
of  soon,  and  do  not  support  life  long,  for,  beyond  the  means  em- 
ployed of  condensation  of  food  by  evaporation  of  water  and  compres- 
sion, it  is  not  possible  to  "  concentrate "  nourishment  very  much. 
Making  food  assimilable  and  more  useful  is  another  matter  from 
concentrating  it  in  the  sense  that  it  may  be  made  to  support  an  able- 
bodied  man  and  supply  him  with  energy  for  a  day's  work,  for  ex- 
ample, of  mountain  climbing. 

Xeither  does  such  predigested  aliment  represent  concentration  for 
an  invalid  ;  the  bulk  of  food  given  is  certainly  reduced,  and  its  assimila- 
tion may  be  improved,  but  it  does  not  convey  into  the  body  any  phe- 
nomenal quantity  of  latent  force  units  or  of  heat  units.  It  is  im- 
portant to  understand  this  fact;  otherwise  serious  misconceptions 
arise  as  to  the  actual  amount  of  nutriment  which  a  patient  fed  exclu- 
sively on  peptonoids  and  similar  food  preparations  is  receiving. 

It  should  l)e  remembered  that  many  of  the  fluid  meat  prepara- 
tions contain  from  12  to  20  per  cent  of  alcohol,  used  as  a  preservative 
and  diluent,  and  if  given  in  large  quantity  or  for  a  long  time,  the 
patient  may  take  too  much  alcohol. 

The  following  analyses  illustrate  the  comparative  composition  of 
several  of  the  preceding  preparations  as  given  by  Chester: 


ANIMAL   FOODS 


141 


Composition  of  Meat  Extracts. 
(Albert  H.  Chester.) 


Water. 

Organic 
matter. 

Ash. 

Soluble 
albumin. 

Alcholic 
extract. 

Liebig's  extract   

18  27 

58  48 

23  25 

0  05 

44.11 

Benger's  extract  of  beef  

40  65 

39  85 

19  50 

1  11 

13  18 

Valentine's  meat  juice  

54  40 

31  84 

13  75 

0  44 

26  32 

In  some  meat  extracts  creatin  predominates,  in  others  creatinin. 
The  range  of  each  is  from  1  to  4  per  cent.  Fresh  meat  contains  only 
creatin,  which  is  readily  converted  into  creatinin,  and  both  may  re- 
appear in  the  urine  after  a  proteid  meal. 


VARIOUS    MEATS. 

Beef  tongue  is  a  tender  form  of  meat,  but  it  contains  rather  too 
much  fat  to  agree  well  with  delicate  stomachs. 

Veal. —  Veal,  especially  when  obtained  from  animals  killed  too 
young,  is  usually  tough,  pale,  dry,  and  indigestible;  but  when  the 
animals  are  slaughtered  at  the  right  age  the  meat  is  sometimes  tender, 
and  is  regarded  by  many  as  nutritious.  It  differs  considerably  from 
beef  in  flavor,  and  contains  more  gelatin  and  water  but  less  fat  and 
protein.  Veal  broth  is  nutritious,  and  affords  a  wholesome  variety 
in  the  dietary  for  the  sick.  When  too  much  is  given  it  may  excite 
diarrhoea.  Veal  is  much  more  used  for  invalids  in  Germany  than 
elsewhere,  although  it  figures  less  conspicuously  in  hospital  dietaries 
there  now  than  formerly.  Bauer  declares  it  to  be  more  digestible 
than  beef,  but  Pavy  says,  referring  to  both  veal  and  lamb,  "  they  are 
meats  that  it  is  desirable  to  avoid,  generally  speaking,  in  case  of 
dyspepsia,"  and  this  opinion  is  prevalent  in  America  as  well  as  in 
England. 

Mutton. —  Mutton  is  rated  as  more  digestible  than  beef  by  Eng- 
lish writers  upon  dietetics.  That  can  hardly  be  said  to  be  the  case 
in  this  country,  where  the  quality  of  beef  has  been  so  much  im- 
proved of  late  years,  and  where  average  mutton  is  not  so  tender  as 
in  England.  For  example,  Balfour  writes  in  his  work  upon  the 
Senile  Heart :  "  "We  also  recommend  meat  with  short  fiber,  such  as 
chicken,  rabbit,  game,  mutton,  or  well-grown  lamb,  in  preference  to 
such  meats  as  beef,  whose  fibers  are  long  and  tough."  Fat  mutton 
is  richer  in  fat  than  beef,  is  certainly  less  digestible  than  lean  beef, 
and  tough  mutton  is  quite  as  difficult  of  digestion  as  tough  beef,  and 
in  America  it  is  harder  to  obtain  it  tender.  Mutton  fat  contains  a 


142          FOODS  AND  FOOD  PREPARATIONS 

larger  percentage  of  stearic  acid,  which  makes  it  firmer  and  less 
digestible  than  beef  fat.  When  properly  assimilated  after  digestion, 
mutton  possesses  equal  nutrient  value  with  beef. 

Mutton  broth  is  wholesome  and  suitable  for  the  sick  and  may  be 
given  in  typhoid  and  other  fevers.  It  is  slightly  constipating. 

Lamb. —  Lamb,  when  very  tender  and  of  just  the  right  age,  is 
quite  as  digestible  as  beef  or  mutton,  but  the  flesh  contains  too  large 
a  proportion  of  fat  —  more  than  is  present  in  veal.  Good  lamb  is  ex- 
pensive, and,  on  account  of  the  uncertainty  of  the  character  of  the 
meat,  is  not  usually  to  be  recommended  for  invalids. 

Venison. —  Venison  is  a  tender  meat  with  short  fibers,  which  is 
very  digestible  when  obtained  from  young  deer,  but  is  often  eaten 
when  aged  to  a  degree  which,  while  some  think  it  improves  the  flavor, 
unfits  it  for  dyspeptics.  The  meat  corresponds  very  closely  in  chemi- 
cal composition  to  lean  beef. 

Pork  is  a  tender-fibered  meat,  but  is  notoriously  indigestible  on  ac- 
count of  the  high  percentage  of  fat  present,  which  may  exceed  37  per 
cent,  or  considerably  more  than  the  quantity  of  its  proteid.  Pork 
ribs  may  have  as  much  as  42  per  cent  of  fat.  The  fat  is  composed 
chiefly  of  palmitic  and  oleic  glycerides. 

Ham  and  Bacon. —  Bacon  is  much  more  digestible  than  pork,  and 
ham  occupies  a  variable  position,  according  to  its  quality  and  leanness. 
On  an  average,  100  grams  of  ham  give  30  of  albuminates  and  32  of 
fat;  the  salt  ranges  between  7  and  1  per  cent"  (Bauer). 

In  Germany,  and  especially  at  Carlsbad  and  other  mineral  springs, 
ham  is  much  prescribed  in  invalid  dietaries.  It  is  often  given  scraped 
or  "  rasped."  Bauer  says  (Dietary  of  the  Sick)  :  "  The  flesh  of 
£he  hog  seems  to  be  better  adapted  for  smoking  than  that  of  other 
animals,  and  long  experience  compels  us  to  recognize  smoked  ham  as 
one  of  the  wholesomest  forms  of  meat.  Whether  boiled  or  eaten 
raw,  it  seems,  as  a  rule,  to  be  more  easily  digested  by  weak  organs 
than  almost  any  other."  An  opposite  view  is  prevalent  in  England 
and  America,  where  it  is  less  used  for  the  sick.  So  distinguished  a 
dietitian  as  Pavy  omitted  mention  of  it  in  his  book  upon  Food  and 
Dietetics.  Ham  is  more  digestible  when  thoroughly  boiled,  cut  thin, 
and  eaten  cold.  It  should  not  be  fried  for  invalids.  Hot  ham  is 
very  indigestible. 

If  cut  thin  and  cooked  crisp,  fat  bacon  is  friable  and  easily  broken 
into  small  particles  during  digestion.  It  often  may  be  eaten  by  dys- 
peptics, and  forms  an  excellent  variety  of  fatty  food  for  consump- 
tives. 

It  ha?  been  proved  at  the  Minnesota  Agricultural  Experiment  Sta- 


ANIMAL  FOODS  143 

tion  that  not  only  is  96  per  cent  of  bacon  fat  digested  and  absorbed, 
but  this  form  of  fat  may  increase  the  digestibility  of  other  foods, 
when  cooked  or  eaten  with  them,  as  for  example,  with  baked  beans. 
Bacon  contains  as  much  protein  as  other  meats,  and  double  the  per- 
centage of  fat.  In  the  ordinary  ration  of  armies  or  institutions  it 
proves  less  monotonous  than  corned  beef  or  boiled  beef,  and  it  facili- 
tates the  cooking  of  other  foods.  After  our  troops  in  the  Philippines 
were  deprived  of  bacon  in  their  rations,  it  was  found  that  they 
spent  their  wages  to  buy  lard  for  frying,  showing  their  need  of  fat 
food. 

Horseflesh  is  a  nutritious  meat  for  those  who  are  not  fastidious. 
It  is  consumed  in  large  quantities  by  the  poor  in  France  (where  over 
5,000  tons  are  eaten  annually  in  Paris  alone),  and  to  some  extent 
in  Denmark,  Sweden,  Germany,  and  Austria.  It  has  never  found 
favor  in  England  or  the  United  States,  and  most  of  the  horseflesh 
butchered  in  this  country  is  canned  for  consumption  by  foreigners. 
It  contains  neurin,  and  its  excessive  use  may  cause  diarrhoea. 

Rabbit  has  white  meat,  and  Belgian  hare  meat  is  partially  white, 
but  they  are  not  proper  invalid  foods. 

Fowl. —  Chicken  is  among  the  most  digestible  of  meats  for  inva- 
lids, whether  cooked  by  broiling,  roasting,  or  boiling,  because  its  fiber 
is  tender  and  contains  little  fat.  The  white  meat  is  more  easily  di- 
gested than  the  dark,  although  it  differs  very  slightly  in  chemical 
composition.  Dark  meat  of  fowl  contains  more  pigment,  extractives 
and  a  little  more  proteid  than  white  meat.  The  breast  of  chicken 
may  be  given  to  a  typhoid  convalescent  or  a  patient  recovering  from 
any  severe  illness  before  beef  and  mutton  are  allowed.  Chicken  broth 
is  almost  universally  liked,  and  when  thickened  with  rice,  and  some- 
times with  an  egg,  it  forms  a  highly  desirable  invalid  food. 

"  Broilers "  contain  about  20.7  per  cent  of  proteid  and  7  to  8 
per  cent  of  fat.  In  young  chickens  the  dark  meat  contains  only 
one  per  cent  less  proteid  than  the  white  meat  and  one  per  cent  more 
fat. 

Capon,  or  the  emasculated  cock,  develops  a  larger  proportion  of 
white  meat  than  the  chicken,  and  is  very  digestible. 

The  white  meat  of  fowl  is  popularly  supposed  to  contain  less  pro- 
tein, and  therefore  be  less  "  heavy  "  as  an  article  of  diet  than  red 
meat,  such  as  steak  or  roast  beef.  The  chemical  differences  are,  how- 
ever, very  slight.  Chicken  contains  between  3  and  4  per  cent  more 
protein  than  sirloin  steak  and  about  half  as  much  fat.  Eed  meat 
contains  more  pigment,  but  somewhat  less  of  creatin  and  other  extrac- 
tives than  the  white  meat  of  chicken.  The  fiber  of  the  latter  is  some- 


144          FOODS  AND  FOOD  PREPARATIONS 

what  more  tender,  as  a  rule,  and  hence  slightly  more  digestible  than 
that  of  beef  or  mutton,  although  the  protein  content  is  somewhat 
greater.  As  the  white  meat  of  chicken  and  game  is  relatively  expen- 
sive, patients  are  less  likely  to  eat  too  much  of  it,  as  they  may  do  with 
beef.  Helen  W.  Atwater  says: 

"  As  far  as  the  nutritive  value  alone  is  concerned,  the  general 
advantage  of  poultry  over  the  other  meats  thus  appears  to  be  that, 
pound  for  pound,  it  contains  very  slightly  more  of  the  building  mate- 
rials needed  by  the  body;  its  disadvantage  is  that  it  furnishes  less  of 
the  energy-giving  material  than  the  fatter  meats." 

The  clinical  significance  of  these  observations  is  very  important, 
for  in  cases  of  chronic  nephritis,  gout,  rheumatism,  lithaemia  and 
allied  conditions,  patients  are  often  told  that  they  must  abstain  from 
mutton,  beef  and  other  red  meats,  but  are  allowed  to  eat  the  white 
meat  of  chicken,  turkey,  etc.  In  reality,  however,  there  is  little 
advantage  in  this  from  the  standpoint  of  the  quantity  of  proteid  mate- 
rial introduced  into  the  system  and  of  resultant  proteid  waste.  The 
question  is,  therefore,  almost  entirely  one  of  relative  digestibility, 
of  physical  rather  than  chemical  properties,  a  fact  which  should  be 
more  widely  appreciated. 

Turkey  is  sometimes  as  digestible  as  chicken,  as  to  the  white 
meat,  but  it  is  often  tough,  and  the  dark  meat  is  much  less  digest- 
ible. 

Guinea-fowl  and  peafowl  are  very  digestible  and  wholesome  when 
young  or  caponized.  These  birds  are  somewhat  darker  in  the  color 
of  their  meat,  and  richer  in  protein  than  chicken,  but  poorer  in  fat. 
They  contain  as  much  nourishment  as  medium  beef  or  mutton,  and 
their  flavor  is  delicate. 

Young  pigeons  are  quite  digestible,  and  the  breast  of  a  squab 
may  be  given  to  a  convalescent  from  fever  before  other  meat  is  al- 
lowed. 

Tame  ducks  and  geese  are  indigestible  unless  quite  young  and 
tender,  on  account  of  containing  too  much  fat.  Goose  meat  may 
sometimes  hold  over  40  per  cent  of  fat,  with  which  it  is  thoroughly 
infiltrated,  and  ducklings  38  per  cent  of  fat,  as  against  14  per  cent 
of  protein. 

Game,  such  as  the  flesh  of  partridge,  grouse,  woodcock,  snipe,  quail, 
pheasants,  wild  clucks,  prairie  chickens,  etc.,  is  by  many  persons  pre- 
f erred  when  it  is  "high"-  — that  is,  when  it  has  been  kept  long 
enough  for  putrefactive  changes  to  occur.  These  may  originate  in 
the  meat  itself  or  in  the  viscera  which  have  not  been  removed  and 
from  which  the  odor  and  flavor  of  commencing  putrefaction  are  de- 


ANIMAL  FOODS  145 

rived  and  penetrate  the  meat.  When  the  meat  itself  is  not  perfectly 
fresh  it  may  produce  violent  gastrointestinal  disorder,  but  many 
persons  with  good  digestive  organs  are  not  disturbed  by  the  consump- 
tion of  such  food  in  moderation,  provided  it  is  well  cooked.  The 
process  of  cooking  disinfects  it  by  heat.  The  fat  of  old  birds  is  too 
strongly  flavored,  and  their  meat  is  tough.  Young  birds  are  digestible 
if  properly  cooked.  Game  is  rich  in  extractives. 

Other  forms  of  meats  derived  from  the  larger  animals,  such  as 
the  wild  boar,  wild  sheep  and  goats,  etc.,  are  too  numerous  for  de- 
tailed mention  here,  as  they  rarely  are  made  use  of  except  by  hunters, 
explorers,  or  natives  of  wild  countries.  It  is  a  peculiarity  of  game 
in  general  that  it  usually  cannot  be  eaten  continuously  as  long  as  beef 
without  palling  very  much  sooner  upon  the  appetite. 

ANIMAL    VISCERA 

Animal  viscera  are  eaten  to  some  extent  in  this  country,  and  some 
of  them  are  digestible,  although  none  are  as  nutritious  as  good  meat, 
and  they  contain  little  nitrogen.  With  the  exception  of  sweetbread, 
and  in  some  cases  the  thyroid  gland,  they  should  not  be  given  to  the 
sick. 

Sweetbread  is  the  most  useful  in  the  invalid  dietary.  It  consists  of 
the  pancreas  of  the  calf,  called  by  butchers  "  stomach  sweetbread  " 
to  distinguish  it  from  the  thymus  gland  of  the  same  animal,  called 
also  the  "  neck "  or  "  throat  sweetbread."  Either  gland  is  tender 
and  digestible,  the  thymus  somewhat  more  so  than  the  pancreas,  which 
has  larger,  more  "  stringy  "  blood  vessels. 

The  thyroid  gland  has  lately  been  shown  to  possess  remarkable 
power  in  regulating  disordered  nutrition  in  cases  of  myxcedema,  cre- 
tinism, obesity,  chronic  skin  diseases,  epilepsy,  and  some  forms  of  in- 
sanity. It  is  usually  given  as  a  powdered  extract  in  five-grain  doses, 
two  or  three  times  a  day,  but  it  is  sometimes  cooked  fresh  and  eaten  as 
a  food. 

Tripe,  made  from  the  third  stomach  of  the  cow,  when  tender  and 
well  cooked  is  easy  to  digest,  although  somewhat  too  fat.  It  con- 
tains about  16  per  cent  of  fat  and  13  per  cent  of  albuminoids  — 
rather  more  than  most  viscera. 

The  heart  is  sometimes  eaten,  but  the  meat  is  tough  and  unde- 
sirable. 

Liver  and  kidneys  are  eaten  more  than  any  other  viscera.  If 
cooked  too  long  they  become  very  hard  and  tough.  Calf's  liver  is 
always  better  flavored  and  more  tender  if  the  animal  has  had  fresh 


146         FOODS  AND  FOOD  PREPARATIONS 

milk  for  food  and  not  boiled  skimmed  milk  and  slops.  Tender  liver 
is  more  easily  digested  than  kidney,  and  is  fairly  nutritious.  It 
should  not  be  allowed  diabetics.  These  foods  are  often  fried  or  stewed 
in  rich  sauces  or  "  devilled,"  all  of  which  are  indigestible  modes  of 
cooking. 

Brains  are  fairly  digestible,  but  not  nutritious;  they  contain  too 
much  fat  and  cholesterin  for  invalids. 

Blood  has  sometimes  been  used  as  a  fluid  food.  Formerly  there 
was  a  fashion  among  consumptives  of  going  to  the  abattoirs  to  drink 
it  warm,  in  the  belief  that  it  had  some  specific  curative  value  for 
tuberculosis.  This,  however,  is  not  the  case,  and  it  nauseates  most 
persons  to  taste  it,  if  not  to  look  at  it. 

Isinglass  —  Gelatin 

Isinglass  is  derived  from  the  membrane  of  the  swimming  blad- 
der of  the  sturgeon,  but  that  of  other  fishes  is  occasionally  used.  It 
is  not  very  soluble  in  the  crude  state,  but  is  hygroscopic  and  swells 
very  much  in  cold  water.  It  dissolves  in  boiling  water,  and  when  the 
water  is  evaporated  again  hardens. 

Gelatin. —  The  collagen  of  tendons  and  ossein  of  bones  are  proteids 
which  yield  gelatin  and  glue.  Gelatin  is  also  derived  from  ten- 
dons and  fascia.  Gelatin  is  a  substance  the  potential  energy  of  which 
is  calculated  as  being  even  more  than  that  of  some  fats  and  albu- 
minates,  yet  in  the  body  it  is  very  inferior  in  the  production  of 
force. 

It  is  a  curious  and  interesting  property  of  gelatin  that  used  alone 
it  fails  to  have  much  nutritive  power,  but  in  proper  combination  with 
other  foods  it  is  a  useful  aliment.  "  By  the  addition  of  gelatin  very 
large  quantities  of  albumin  can  be  spared  in  the  body  or  devoted  to 
increase  of  bulk,  just  as  by  the  supply  of  fats  and  carbohydrates  " 
(Bauer). 

It  cannot  wholly  replace  albumin,  the  loss  of  which  still  goes  on  to 
some  extent  even  when  gelatin  is  eaten  in  large  quantity.  It  also 
slightly  spares  the  consumption  of  non-nitrogenous  materials.  This 
is  a  question  of  considerable  importance  in  the  feeding  of  invalids, 
because,  while  many  jellies  are  easily  digested  and  are  agreeable  to  the 
palate,  it  is  useless  to  burden  the  stomach  with  them  if  they  do  not 
possess  nutritive  properties  in  proportion  to  other  foods,  and  the 
matter  therefore  must  be  discussed  somewhat  in  detail. 

Since  bones  consist  of  nearly  two-thirds  of  their  weight  of  gela- 
tin, the  latter  may  be  used  advantageously  as  an  inexpensive  means 


ANIMAL  FOODS  147 

for  furnishing  variety  in  the  diet  by  addition  to  meat  broths  and 
jellies,  pea  and  bean  soups,  etc.  M.  Edwards  says  that  the  proper 
proportion  for  such  mixtures  should  be  at  least  one-fourth  of  meat 
soup  to  three-fourths  of  gelatin  soup.  The  bones  themselves  may  be 
broken  and  made  to  yield  fat  and  gelatin  for  soup  "stock." 

Edible  birds'  nests  are  not  true  gelatin,  but  a  Chinese  food  product 
allied  to  mucin. 

Gelatinous  substance  may  be  obtained  from  boiling  for  several  con- 
secutive hours  such  material  as  calves'  feet,  sheep's  trotters,  ox  tails, 
etc.,  and  after  clarifying,  straining,  and  concentrating,  very  palatable 
jellies  may  be  made,  to  which  chicken  or  mutton  is  added  for  invalid 
use. 

Calf's-foot  jelly  and  calf's-head  jelly,  if  not  made  too  rich  by  added 
ingredients,  make  suitable  invalid  dishes,  but  ox-tail  soup  is  too  rich 
for  the  sick. 

Pure  white  gelatin  is  insipid,  and  is  almost  impossible  to  eat  in 
considerable  quantity  unless  it  is  well  seasoned.  If  free  from  all 
gluey  taste  and  odor,  and  prepared  with  coffee  or  lemon  juice,  or 
other  fruit  flavors,  it  makes  an  easily  digested  invalid  food.  Or  it 
may  be  combined  with  eggs  or  milk  as  blancmange.  The  addition  of 
meat  extracts  to  it  improves  the  taste,  and  the  admixture  of  wine, 
like  good  sherry,  alters  the  taste  rather  by  the  introduction  of  its 
aromatic  principles  than  by  the  alcohol  itself,  which  is  largely  evap- 
orated from  the  jelly. 

Gelatin  has  been  used  as  a  food  in  cases  of  haemophilia,  purpura 
hemorrhagica  and  other  forms  of  continued  bleeding,  with  the  idea 
that  it  thickens  the  blood,  or  in  some  manner  promotes  coagulation, 
but  in  those  cases  in  which  I  have  given  it  the  effect  was  inappreciable. 
It  also  has  been  used  for  this  purpose  subcutaneously. 

Dry  gelatin  contains  17.3  per  cent  of  nitrogen,  which  is  a  larger 
proportion  than  is  contained  in  albumin;  consequently  urea  excre- 
tion is  decidedly  increased  by  gelatin  feeding.  Diuresis  is  also 
produced,  and  the  desire  for  liquid  is  intensified,  so  that  a  large 
proportion  of  gelatin  in  the  diet  causes  decided  physiological 
effects. 

Sea  Food 

Fish. —  The  annual  quantity  of  sea  food  produced  in  the  fresh  and 
salt  waters  of  the  United  States  is  more  than  2,000,000,000  Ibs. 

Fish  vary  both  in  digestibility  and  nutritive  qualities.  The  chief 
differences  are  in  regard  to  coarseness  of  fiber  and  the  quantity  of 


148         FOODS  AND  FOOD  PREPARATIONS 

fat  present.  Fish  meat  is  less  stimulating,  sustaining,  and  satisfying 
than  that  of  birds  or  mammals. 

Eels  contain  a  large  proportion  of  fat,  which  amounts  to  28  per 
cent.  Herring  have  7,  salmon  about  6.05,  whereas  sole  have  but  0.25 
per  cent  (Konig).  Mackerel,  trout,  and  shad  contain  considerable 
fat. 

Fish  which,  like  the  salmon,  are  rich  in  flavor  and  fat,  although 
they  may  be  very  nutritious,  are  much  less  easy  of  digestion  than  are 
the  simpler  varieties,  such  as  sole  or  flounders  and  fresh  codfish. 
Dried  codfish  may  be  eaten  on  long  sea  voyages  day  after  day  without 
the  repulsion  which  is  soon  excited  by  the  continuous  diet  of  the  more 
highly  flavored  fatty  fish. 

The  flesh  of  many  fish  contains  a  large  percentage  of  water,  be- 
sides gelatin. 

The  following  fish,  in  the  order  named  by  Walker,  have  the  largest 
percentage  of  albuminoids:  Red  snapper,  whitefish,  brook  trout, 
salmon,  bluefish,  shad,  eels,  mackerel,  halibut,  haddock,  lake  trout, 
striped  bass,  cod,  flounder. 

All  fish  are  best  in  their  proper  season,  for  out  of  season  they  de- 
teriorate from  change  in  food  or  other  causes,  and  are  less  nutri- 
tious, besides  possessing  inferior  flavor,  and  sometimes  disagreeable 
odor.  They  should  be  eaten  as  fresh  as  possible,  for  there  are  few 
alimentary  substances  capable  of  exciting  so  violent  gastrointestinal 
disturbance  as  decomposing  fish.  Vivid  red  gills  and  fullness  and 
brightness  of  the  eye  are  a  test  of  freshness. 

The  ferments  which  decompose  fish  continue  to  act  at  temperatures 
sufficiently  low  to  inhibit  those  of  meat,  hence  fish  should  be  frozen 
and  not  merely  refrigerated  for  preservation,  but  the  practice  of  pre- 
serving fish  frozen  is  open  to  the  objection  that  the  cold  prevents 
malodors  from  revealing  commencing  putrefaction,  when  they  be- 
come more  or  less  toxic  for  most  persons,  although  the  Javanese  eat 
putrid  fish,  and  the  Scandinavians  prepare  a  variety  of  fermented 
fish  as  a  standard  food. 

It  is  a  popular  fallacy  that  fish  constitute  a  good  "  brain  food  " 
on  account  of  containing  a  large  percentage  of  phosphorus,  a  prom- 
inent ingredient  of  nerve  tissue ;  but  in  reality  many  fish  contain  less 
of  this  clement  than  meat,  and  neither-  Eskimos  nor  other  aborignal 
tribes  who  live  largely  upon  fish  are  noted  for  intellectuality.  Fish 
contain  less  fat  than  moat,  averaging  2-5  per  cent.  They  contain 
more  gelatin  and  collagen,  and  less  extractive  than  meat. 

The  following  table  of  fish  composition  is  condensed  from  analyses 
given  bv  C,  F.  Langworthv : 


ANIMAL  FOODS 


149 


Composition  of  Fish. 


Kind  of  food  material. 

Water. 

Protein 
by  factor 

(N  X 
6.a5). 

Fat. 

Carbo- 
hy- 
drates. 

Ash  or 
mineral 
matter. 

Total 
nutri- 
ents. 

Fuel 
value 
per  Ib. 

FRESH  FISH 

Alewife,  whole   

Per  ct. 
37.6 

Per  ct. 

9.8 

Per  ct. 
2.4 

Per  ct. 

Per  ct. 

0.8 

Per  ct. 
13.0 

Cal. 
277 

Bass,  sea,  dressed    

42.2 

10.5 

.2 

.7 

11.4 

200 

Bass,  striped    dressed   

37.4 

8.8 

2.2 

.5 

11.5 

249 

Blackfish,   dressed    

35.0 

8.4 

.5 

.5 

9.4 

172 

Bluefish,  dressed    

40.3 

10  0 

.6 

.7 

11.3 

204 

Butterfish,    dressed    

45.8 

11.8 

7.2 

7 

19.7 

503 

Carp    (European  analysis)  . 

48.4 

.7 

.9 

14.5 

263 

Cod,  dressed    

58  5 

11  1 

0  2 

0  8 

12  1 

209 

Cusk,  dressed   

49.0 

10.1 

.1 

.5 

10.7 

186 

Eel,  saltwater,  dressed   .... 

57.2 

14.8 

7.2 

.8 

22.8 

558 

Flounder,  common,  dressed  . 

35.8 

6.4 

.3 

.6 

7.3 

127 

Hake,  dressed   

39.5 

7.3 

.3 

.5 

8.1 

145 

Haddock,    dressed    

40.0 

8.4 

.2 

.6 

9.2 

159 

Halibut,  dressed  

61.9 

15.3 

4.4 

.9 

20.6 

454 

Herring,  whole   

41.7 

11  2 

3.9 

.9 

16.0 

363 

Mackerel,   dressed    

43  7 

11  6 

3  5 

7 

15.8 

354 

Mackerel,  Spanish,  dressed. 

51.4 

16.3 

7.2 

1.2 

24.7 

585 

Mullet,  dressed   

38.2 

9  9 

2.4 

.6 

12.9 

277 

Perch,  white,  dressed   

34.4 

8.8 

1.8 

.5 

11.1 

231 

Perch,  yellow,  dressed  

50.7 

12.8 

.7 

.9 

14.4 

259 

Pickerel,  dressed    

51.2 

12  0 

2 

.7 

12.9 

227 

Pollock,  dressed  

54  3 

15  4 

6 

11 

17  1 

304 

Pompano,   whole    

39.5 

10.3 

4.3 

.5 

15.1 

358 

Porgv,  dressed    

34.6 

8.6 

2.4 

.7 

11.7 

254 

Red-grouper,   dressed  

35.0 

8.5 

.2 

.5 

9.2 

163 

Red-snapper,  dressed  

43.7 

10.6 

.3 

.7 

11.6 

204 

Salmon,  Calif,    (sections)  .  . 

57.9 

16.7 

14.8 

.9 

32.4 

903 

Shad,  dressed    .  . 

39.6 

10.6 

5.4 

.8 

16.8 

408 

Shad,  roe   

71.2 

23.5 

3.8 

1.5 

28.8 

581 

Smelt    whole   

46  1 

10.1 

1.0 

1.0 

11.1 

222 

Sturgeon,   dressed    

67  4 

15.1 

1.6 

1.2 

17.9 

340 

Tomcod,  dressed   

39  6 

8.4 

.3 

.5 

9.2 

163 

Trout,  brook,  dressed    

48  4 

11.9 

1.3 

.7 

13.9 

268 

Trout,  lake,  dressed    

44  4 

11.0 

6.2 

.7 

17.9 

449 

Turbot,  dressed  

43  1 

8  9 

8  7 

.8 

18.4 

513 

Weakfish,   dressed    

46  1 

10  4 

1.3 

.7 

12.4 

240 

Whitefish,  dressed   

39  4 

12.8 

3.6 

.9 

17.3 

376 

General     average     of     fresh 
fish  as  sold                

44.6 

10.9 

2.4 

.7 

41.0 

295 

Sardines,  canned 

53.6 

23.7 

12.1 

5.3 

14.1 

916 

Some  fish  contain  different  species  of  tapeworm,  but  they  are  seldom 
transmitted  to  man.  The  sturgeon  is  the  intermediate  host  of  the 
Dibotliriocephalus  latus,  and  when  eaten  raw  or  pickled,  in  Finn- 
land  and  Russia,  give  rise  in  man  to  a  very  pernicious  type  of  anaemia. 

Fish  having  white  meat  constitute  an  excellent  food  for  invalid 
diet,  and  when  cooked  by  boiling  or  broiling  (not  frying)  they  may 
be  given  to  convalescents  and  to  those  with  feeble  gastric  powers. 


150         FOODS  AND  FOOD  PREPARATIONS 

The  most  digestible  fish  are  fresh  sole,  whiting,  bluefish,  white- 
fish,  bass,  red-snapper,  fresh  codfish,  halibut,  shad,  and  smelt.  Pavy 
says :  "  Of  all  fish,  the  whiting  may  be  regarded  as  the  most  delicate, 
tender,  easy  of  digestion,  and  least  likely  to  disagree  with  a  weak 
stomach.  The  haddock  is  somewhat  closely  allied,  but  has  a  firmer 
texture  and  is  inferior  in  flavor  and  digestibility." 

Crimping  is  a  process  sometimes  applied  to  fresh  fish,  like  the  cod, 
by  which  the  firmness  of  the  flesh,  as  well  as  its  flavor,  is  increased. 
As  soon  as  caught,  the  fish  is  incised  transversely  by  numerous  deep 
cuts.  On  being  plunged  into  ice-cold  water,  the  muscle  fibers  con- 
tract firmly  and  so  remain. 

As  a  rule,  dried,  smoked,  or  pickled  fish  should  not  be  given  to 
invalids,  although  thoroughly  boned  and  desiccated  or  "  shredded " 
codfish  is  quite  tender.  The  latter  process  is  now  conducted  by  ma- 
chinery, and  thus  prepared  the  fish  requires  less  prolonged  soaking 
and  cooking. 

Fish  roe  is  not  very  nutritious,  and  it  serves  mainly  as  a  relish. 
Shad  roe,  thoroughly  cooked,  is  not  objectionable,  but  sturgeon's 
roe  or  caviare,  which  is  sometimes  used  as  an  "  appetizer,"  is  capable 
of  arresting  digestion,  especially  when  old,  black,  or  rancid.  Caviare 
contains,  according  to  analyses  by  Kb'nig  and  Brimmer,  water,  45.05 ; 
proteids,  31.90;  fat,  14.14;  salts,  8.91  per  cent. 

It  should  not  be  forgotten  that  some  persons  cannot  digest  fish  of 
any  kind,  or  at  most  can  take  but  one  or  two  varieties  without  pro- 
voking an  attack  of  dyspepsia,  biliousness  or  urticaria.  A  few  tropi- 
cal fish  are  poisonous,  and  constitute  an  exception  to  the  general  edi- 
bility of  vertebrate  animals.  (See  Fish  Poisoning.) 

Tli  ere  are  no  diseases  in  which  a  fish  diet  possesses  specific  value, 
but  often  in  chronic  Bright's  disease,  lithaemia,  gout,  or  other  condi- 
tions in  which  it  is  undesirable  to  give  much  meat,  it  is  very  service- 
able as  a  compromise. 

Crustaceans. —  Lobsters,  crabs,  and  shrimps,  although  they  consti- 
tute a  wholesome  food,  when  absolutely  fresh,  for  those  in  health 
should  never  be  admitted  to  an  invalid  dietary.  They  are  all  scaven- 
gers of  the  sea,  and  crabs  not  thoroughly  cleaned  or  imperfectly  cooked 
may  be  poisonous  from  contamination  with  putrid  matter,  although 
their  own  flesh  is  good.  Soft-shell  crabs  are  by  no  means  always 
"  soft  "  when  eaten,  and  their  shells  furnish  a  large  bulk  of  indigesti- 
ble residue,  which  may  prove  irritating,  giving  rise  to  intestinal  colic 
and  diarrhcca. 

Lobsters  are  highly  poisonous  to  some  persons  even  when  fresh, 
and  especially  if  eaten  with  other  food  they  may  excite  nausea,  vomit- 


ANIMAL  FOODS  151 

ing,  and  gastroenteritis.  In  others  they  may  cause  urticaria  or  in- 
tensify existing  skin  eruptions. 

Shrimp  resemble  lobsters  in  general  composition  and  digestibility, 
and  the  meat  of  these  crustaceans,  stripped  for  canning,  contains  be- 
tween 18  and  25  per  cent  of  protein  and  a  mere  trace  of  fat  and 
carbohydrate. 

Canned  crustaceans  are  very  often  the  cause  of  gastrointestinal  dis- 
order. Potted  shrimp,  crabs,  etc.,  are  liable  to  decomposition  and 
may  produce  ptomaine  poisoning. 

Shellfish. —  Oysters,  clams,  scallops,  and  mussels  are  slightly  nu- 
tritious food,  and  oysters,  at  least,  when  fresh  and  properly  cooked, 
are  an  excellent  invalid  aliment.  Oysters  often  may  be  digested  ear- 
lier than  meat  in  convalescence  from  fevers,  and  in  many  forms  of 
gastric  disorder.  The  flavor  of  oysters  depends  much  upon  the  place 
in  which  they  are  grown.  When  taken  out  of  salt  water  they  are 
quickly  decomposed  by  bacterial  fermentation.  Prejudice  against 
eating  raw  oysters  has  arisen  of  late  years  owing  to  the  prevailing 
practice  of  transplanting  them  to  sewer-beds  to  be  "  fattened  "  before 
being  marketed.  In  this  way,  being  scavengers,  they  are  likely  to 
transmit  typhoid  fever  germs  (see  p.  435).  Deep  sea  oysters,  how- 
ever, are  entirely  wholesome  and  may  be  eaten  raw  with  safety.  In 
New  York  city  the  sale  of  oysters  is  under  special  Health  Board  super- 
vision to  guard  against  infection. 

The  "  soft  part "  of  shellfish  is  formed  chiefly  by  the  bulky  liver, 
while  the  tough,  harder  portion  is  mainly  the  muscle  which  attaches 
the  animal  to  its  shell.  This  muscle  is  coagulated  and  rendered 
tougher  by  all  forms  of  cooking;  hence  raw  oysters  are  more  tender 
and  digestible  than  if  stewed  or  broiled.  In  oyster  the  liver  is  rela- 
tively larger  and  more  nutritious  than  in  clams.  In  recommending 
oysters  to  invalids  it  is  always  best  to  allow  only  the  soft  parts  to  be 
eaten,  and  when  this  rule  is  observed  they  may  be  cooked  in  a  variety 
of  ways  —  by  stewing,  broiling,  roasting,  or  "  panning,"  and  steaming 
—  but  they  should  never  be  fried  for  the  sick. 

Both  oysters  and  clams  have  the  advantage  that  they  are  very 
generally  liked,  and  make  a  pleasant  variety  of  food  to  relieve  re- 
stricted diets.  They  impart  an  agreeable  flavor  to  milk  and  broths. 
It  is  customary  to  forbid  their  use  by  diabetics,  on  the  ground  that 
their  livers  contain  glycogen,  but  this  is  so  trifling  in  quantity  as 
scarcely  to  be  worth  consideration.  Clam  juice  or  plain  clam  broth 
is  almost  specific  for  some  forms  of  vomiting,  especially  seasickness. 
It  may  be  tried  in  the  vomiting  of  pregnancy,  and  may  be  retained 
when  beef  juice  and  milk  are  not.  It  is  mildly  stimulating  to  the 


152         FOODS  AND  FOOD  PREPAEATIONS 

gastric  mucous  membrane,  and  slightly  nutritious  and  laxative.  It 
is  best  obtained  fresh,  but  very  good  canned  or  bottle  preparations 
of  it  are  made  which  keep  pure  indefinitely.  It  may  be  taken  either 
hot  or  cold  with  a  little  Cayenne  pepper  half  an  hour  before  a  meal. 
It  seems  to  have  an  invigorating  effect  upon  the  stomach,  and  pro- 
motes the  appetite. 

Oysters  contain  on  an  average  87  per  cent  of  water,  6  of  protein, 
3.3  of  carbohydrates,  and  1.3  of  fat.  Clams  contain  80  per  cent  of 
water,  10.6  of  protein,  5.2  of  carbohydrates,  and  1  of  fats.  Scallops 
contain  14.8  per  cent  of  protein,  3.4  of  carbohydrates,  and  only  0.1 
per  cent  of  fats.  The  total  nutrient  material  in  a  quart  (about 
2  Ibs.)  of  oysters  is  only  between  3  and  5  ounces,  hence  they  are  not 
an  economical  food. 

Mussels  are  less  commonly  eaten  in  this  country  than  in  England 
and  some  parts  of  Europe.  They  belong  in  the  same  category  with 
oysters  and  clams,  and  the  remarks  just  made  in  regard  to  the  latter 
apply  to  them  as  well.  There  is  a  form  of  poisoning  by  mussels 
which  is  exceedingly  dangerous  and  sometimes  fatal.  (See  Poison- 
ing by  Shellfish.) 

In  some  persons  shellfish,  like  crustaceans,  produce  skin  erup- 
tions, such  as  urticaria,  or  aggravate  existing  eczema. 

In  general,  shellfish  are  digested  in  an  hour's  less  time  than  meats. 

INSECTS 

Insects  are  eaten  as  food  in  many  countries,  and  are  dried,  salted 
or  boiled,  especially  by  the  Congo  natives  and  in  South  America. 
Some  American  Indians,  Mexicans  and  Greeks  eat  locusts  and  grass- 
hoppers, which  are  dried  and  ground  to  a  meal.  The  larvae  of  the 
stag  beetle  are  esteemed  in  the  West  Indies.  Large  ants  and  bees 
are  eaten  in  Ceylon.  The  Hottentots  eat  the  white  ant  or  termite,  and 
Chinese  eat  the  silk  worm.  The  only  insect  product  eaten  by  civilized 
man  is  honey  (described  on  page  158). 

IV.  VEGETABLE  FOODS 

Sugars 

Sugars  are  crystallizable  carbohydrates  in  which  oxygen  and  hydro- 
gen exist  in  proportion  to  form  water.  There  are  many  varieties, 
of  which  the  commoner  contained  in  food  or  used  as  an  adjunct 
to  diet  are  cane  sugar  (saccharose  or  sucrose),  grape  sugar  (dextrose 
or  glucose),  levulose  or  fruit  sugar,  and  sugar  of  milk  or  lactose. 


VEGETABLE  FOODS  153 

Inosite,  mannite,  sugar  of  malt  or  maltose,  honey,  a  sweet  nitrog- 
enous substance  called  saccharin,  and  fruit  sugar  or  levulose 
(diabetin)  are  also  used.  Sugar  may  be  derived  from  the  stjems  of 
plants,  as  in  the  case  of  the  sugar  cane,  or  the  palm ;  from  tubers  like 
the  beet,  from  maple-tree  sap,  and  from  other  vegetable  growths. 

The  sugars  present  slight  differences  in  their  physical  properties, 
such  as  specific  gravity,  solubility,  and  effect  upon  polarized  light. 
They  also  differ  in  sweetness  of  taste  and  in  digestibility. 

As  foods,  sugars  have  essentially  the  same  uses  as  starches  (see 
Farinaceous  Foods,  p.  173),  for  all  starch  must  be  converted  into 
dextrin  before  it  can  be  assimilated.  For  this  reason,  sugars, 
although  they  form  an  excellent  class  of  food,  producing  force  and 
heat  and  fattening  the  body,  are  not  absolutely  necessary  for 
the  maintenance  of  health  if  starches  or  fats  are  eaten.  Chauveau 
and  Kaufmann  have  demonstrated  that  during  muscular  activity  the 
consumption  of  sugar  in  the  body  is  increased  fourfold. 

Harley  found  experimentally  that  the  muscle-energy  producing 
effect  of  sugar  is  so  great  that  two  hundred  grams  (seven  ounces) 
added  to  a  small  meal  increased  the  total  amount  of  work  done  from 
6  to  30  per  cent,  and  that  when  sugar  was  added  to  a  large  meal  it 
increased  this  total  from  8  to  16  per  cent. 

In  Holland  sugar  is  much  used  by  athletes  to  lessen  fatigue  in 
rowing.  Steinizer  took  between  10  and  20  ounces  a  day  to  lessen 
muscular  exhaustion  in  strenuous  Alpine  climbing.  Eecent  experi- 
ments in  the  German,  British,  and  other  armies  show  that  a  liberal 
allowance  of  sugars  in  the  diet  tends,  during  manceuvers,  to  main- 
tain strength,  lessen  hunger  and  thirst,  and  the  liability  to  heat  ex- 
haustion. 

They  possess  additional  properties,  in  that  they  have  a  more  agree- 
able flavor  than  starches,  are  more  satisfying  to  the  palate,  and  they 
have  antiseptic  and  preservative  power.  Hence  sugars  and  sirups 
are  extensively  employed  to  preserve  fruits  either  in  solution  or  in 
dried  form,  like  "  candied  "  cherries,  ginger,  etc. 

When  taken  as  food,  sugar  is  quickly  soluble,  and  on  this  account 
taxes  the  digestive  organs  very  little.  Cane  sugar,  however,  needs  to 
be  converted  into  grape  sugar  before  it  can  be  absorbed  and  assimi- 
lated, and  grape  sugar,  which  needs  no  change,  is  therefore  some- 
times spoken  of  as  a  predigested  carbohydrate. 

Between  seven  and  eight  million  tons  of  sugar  are  consumed  each 
year  in  the  world  at  large.  The  English-speaking  nations  are  the 
largest  consumers.  Cane  sugar  was  originally  used  exclusively  in 
preparation  of  medicines,  not  as  a  food. 


154          FOODS  AND  FOOD  PKEPAKATIONS 

Many  persons  acquire  an  inordinate  fondness  for  sugar,  and  con- 
tinued overindulgence  in  this  food  is  sure  to  give  rise  to  flatulent 
dyspepsia,  constipation,  and  disorders  of  assimilation  and  nutrition. 
It  may  cause  functional  glycosuria.  (See  Diabetes.) 

Sugar  is  very  fattening.  In  the  West  Indies  the  negroes  always 
grow  fat  in  the  sugar  season,  when  they  chew  the  cane  in  the  fields. 

Sugars  and  the  TIrine. —  Grape  sugar  or  glucose  and  fruit  sugar 
or  levulose,  when  eaten  in  large  quantity  in  health,  reappear  unal- 
tered in  the  urine,  but  the  latter  sugar  in  diabetes  is  said  by  Moritz 
to  be  consumed  within  the  body.  Sugar  eaten  in  excess  with  other 
food  increases  the  quantity  of  urine  and  feces  and  the  urea  elimination. 

Saccharose,  eaten  in  excess,  occasionally  may  reappear  in  the  urine 
unaltered,  but  oftener  as  glucose. 

Lactose  is  converted  into  glucose,  and  it  produces  functional  gly- 
cosuria more  easily  than  the  latter  if  eaten  in  bulk. 

Alimentary  glycosuria  usually  ceases  in  a  few  hours  after  discon- 
tinuance of  eating  the  food  which  has  caused  it. 

There  are  some  diseases  in  which  sugar  in  all  forms  should  be 
strictly  avoided,  such  as  flatulent  dyspepsia,  acute  and  chronic  gas- 
tritis, gastric  dilatation,  gout,  rheumatism,  obesity,  and  the  uric- 
acid  diathesis,  and  it  should  be  absolutely  forbidden  in  diabetes. 
Temporary  disturbances  of  digestion  from  eating  too  much  sweet 
food  are  very  common,  and  can  usually  be  rectified  by  simple  reme- 
dies, and  by  withholding  or  diminishing  the  customary  allowance  of 
sugar.  Sugar  eaten  constantly  in  excess  destroys  the  appetite  for 
other  food. 

Dextrose  occurs  in  association  with  levulose  in  honey,  grapes,  seeds, 
nuts  and  various  roots,  but  excepting  as  eaten  in  honey  these  sugars 
do  not  constitute  an  important  article  of  diet  as  compared  with 
glucose.  In  the  stomach  they  are  fermented  by  bacteria,  with  forma- 
tion of  lactic  acid. 

Cane  Sugar. —  Cane  sugar,  saccharose,  or  sucrose  is  derived  from 
the  clarified  and  crystallized  juices  of  the  sugar  cane  (saccharum  of~ 
ficinarum),  but  it  may  be  made  also  from  beet  root,  as  originally  dis- 
covered by  Marggraf,  of  Berlin,  in  1747.  The  beet  product  is  some- 
what less  sweet  than  are  the  better  grades  of  cane  sugar.  The  root 
contains  12  to  15  per  cent  of  sugar.  One- third  of  the  world's  com- 
mercial sugar  is  derived  from  sugar  cane,  and  two-thirds  from  beets. 
The  annual  per  capita  consumption  of  sugar  in  the  United  States 
is  Gfi  pounds  and  the  daily  consumption  varies  from  one-half  to 
an  ounce  and  a  half.  About  one-quarter  of  a  pound  per  diem  may  be 
oaten  without  harm.  More  than  this  in  a  short  time  is  liable  to 


VEGETABLE  FOODS  155 

disorder  digestion,  just  as  do  the  equally  diffusible  peptones  eaten 
in  excess. 

Mary  Hinman  Abel,  in  an  exhaustive  study  of  the  food  value  of 
sugar,  says: 

"  There  is  no  proof  that  sugar  is  harmful  to  the  teeth,  although 
doubtless  sweet  food,  allowed  to  cling  to  the  teeth  after  eating,  rapidly 
ferments,  and  acids  will  be  formed  that,  according  to  Professor 
Mill,  of  Berlin,  may  attack  the  teeth.  This  is  equally  true  of  starchy 
foods.  It  is  said,  however,  that  the  negroes  of  the  West  Indies,  who 
consume  enormous  quantities  of  sugar,  have  the  finest  teeth  in  the 
world." 

The  maple  tree  yields  from  2  to  10  per  cent  of  sucrose.  Maple 
sugar  is  eaten  chiefly  as  a  luxury,  on  account  of  its  unique  and 
agreeable  flavor.  It  also  makes  an  excellent  sirup  which  is  in  great 
demand.  Cane  sugar  may  be  obtained  from  the  sugar  pea,  from 
the  flower  buds  of  the  coca  palm,  and  from  other  substances.  It  is 
soluble  in  half  its  weight  of  cold  water  and  in  less  hot  water. 

The  sap  which  is  drawn  from  the  sugar  cane  as  well  as  the  juice 
of  compressed  beet  root  is  not  a  pure  aqueous  solution  of  sugar,  but 
is  mingled  with  other  materials,  chiefly  of  a  mucilaginous  character. 
An  elaborate  process  of  refining  is  applied  in  order  to  produce  the 
commercial  white  sugars  of  various  grades.  The  principal  steps  in 
this  process  are  as  follows :  "  1,  Melting  of  the  sugar ;  2,  straining 
through  bag  filters;  3,  filtering  through  charcoal;  4,  boiling  or 
evaporating  the  decolorized  liquid  in  vacuum  pans;  5,  separation  of 
crystallized  sugar  by  centrifugals."  (Clark.) 

Cane  sugar  was  formerly  sold  more  extensively  than  at  present 
in  the  form  of  coarse  brown  sugar.  This  variety  is  somewhat  im- 
pure, and  on  this  account  has  a  slightly  laxative  action;  but  the 
great  improvements  made  of  late  years  in  the  processes  of  refining 
sugar,  and  the  extreme  cheapness  of  this  commodity,  place  the 
clarified  forms  of  it  within  the  reach  of  all,  and  even  reduce  to  a 
minimum  the  temptation  for  sophistication  which  was  originally 
much  more  extensively  practised,  especially  in  the  adulteration  of 
confectionery,  with  chalk,  .plaster  of  Paris,  etc. 

The  most  highly  refined  cane  sugars  contain  about  0.25  per  cent 
only  of  impurities  and  ash,  but  poorer  grades  hold  1  to  2.3  per  cent, 
with  as  much  water  (Konig).  Cane  sugar  is  about  two  and  a  half 
times  sweeter  than  glucose.  Cane  sugar  is  completely  digested  and 
absorbed,  leaving  no  fecal  residue.  It  is  better  digested  in  propor- 
tion to  the  amount  of  exercise  taken. 

"  Grocer's  itch  "  is  a  form  of  irritation  of  the  skin  of  the  hands 


156         FOODS  AND  FOOD  PREPARATIONS 

sometimes  acquired  from  contact  with  moist  brown  sugar,  adulter- 
ated with  dirt  or  sand  and  mites. 

Caramel. —  By  the  application  of  heat,  at  400°  F.,  refined  cane  sugar 
is  melted,  browned,  and  converted  into  a  non-crystallizable  fluid 
substance  called  caramel,  having  a  slightly  bitter  but  agreeable  taste. 
Comparatively  insipid  farinaceous  food,  such  as  cornstarch  and  farina, 
may  be  flavored  with  it  for  invalid  diet.  Burned  flour  may  be  used 
in  the  same  manner,  but  its  flavor  is  less  agreeable.  Caramel  is  also 
useful  for  flavoring  milk,  custards,  etc. 

At  320°  F.  sugar  melts  to  an  amber  fluid,  which,  on  cooling,  is 
brittle  and  transparent.  In  this  form  it  is  called  "barley  sugar," 
and  is  much  used  in  confectionery. 

When  sugar  is  cooked  with  acid  fruits  it  is  partly  converted  by  the 
heat  and  acid  to  less  sweet  substances,  hence  to  sweeten  cooked 
fruits  the  sugar  should  be  added  when  the  cooking  is  completed. 

Sugar  differs  from  starch  by  containing  another  molecule  of  water. 
Starch,  which  forms  fully  three-fourths  by  weight  of  the  solid  in- 
gredients of  wheat  flour,  is  altered  into  sugar  by  heating  with  a  little 
sulphuric  acid,  or  even  by  prolonged  heating  alone  or  "  torrification." 
The  latter  process  converts  it  into  dextrin,  sometimes  called  "  British 
gum,"  on  account  of  its  substitution  in  commerce  for  gum  arabic. 
With  prolonged  heat  there  is  a  further  change  in  the  starch,  which 
acquires  a  brownish  and  finally  black  hue,  passing  through  a  stage 
analogous  to  the  formation  of  caramel  from  sugar,  and  with  extreme 
heat  forming  a  residue  of  black  carbon,  all  the  water  having  been 
driven  off.  A  hard,  dried,  thoroughly  browned  bread  crust  or  toast 
is  therefore  similar  to  caramel,  and  every  one  is  familiar  with  its 
gain  in  flavor. 

Sugar  candy  is  made  by  extremely  slow  crystallization. 

Sorghum  is  a  variety  of  grass  or  cane  from  which  sugar  may  be 
extracted,  but  in  this  country  it  is  used  more  for  the  manufacture  of 
molasses. 

Candy  and  Confectionery. —  Candy  contains  from  75  to  90  per 
cent  of  sugar,  to  which  may  be  variously  added  butter-  or  other  fats, 
nuts,  fruits,  starch,  glucose,  and  flavoring  extracts.  Cheap  varieties 
are  colored  with  aniline  dyes,  and  are  composed  largely  of  glucose 
and  starch.  Children  assimilate  candy  better  than  adults  because 
they  arc  less  liable  to  dyspepsia,  and  because  of  their  relatively  active 
muscular  energy  and  relatively  large  body  surface  for  losing  heat, 
in  proportion  to  their  size.  They  do  not,  as  a  rule,  care  for  fat 
meat,  arid  prefer  sweets  as  a  natural  substitute. 

Plain  molasses  candy  is  a  wholesome  form  in  which  to  give  sugar 


VEGETABLE   FOODS  157 

to  growing  children,  if  they  are  not  allowed  to  eat  too  much  and 
spoil  their  appetite  for  other  foods.  It  is  mildly  laxative.  Walker 
says. that  "good  candy  is  good  food."  Candies  are  often  made  too 
rich  with  butter,  chocolate,  and  other  ingredients,  when  they  disagree. 

An  infant  taking  two  quarts  of  milk  per  diem  consumes  nearly 
three  ounces  of  sugar  in  the  form  of  lactose.  In  later  childhood  the 
ability  to  digest  starches  replaces  to  some  extent  the  need  for  sugar. 
It  is,  however,  important  that  the  taste  for  candy  and  sugar  common 
to  all  children  should  not  be  permitted  to  interfere  with  a  wholesome 
and  natural  appetite  for  other  foods,  especially  fresh  vegetables  and 
fruits.  The  value  of  sweets  in  the  adult  dietary  has  of  late  years 
found  recognition  in  armies.  The  British  War  Office  shipped  1,500,- 
000  pounds  of  jam  to  South  Africa  as  a  four  months'  supply  for  116,- 
000  troops,  and  one  New  York  firm  during  the  Spanish-American 
War  shipped  over  fifty  tons  of  confectionery  to  the  troops  in  Cuba, 
Porto  Eico,  and  the  Philippines.  The  confectionery  consisted  of 
chocolate  creams,  cocoanut  macaroons,  lemon  and  other  acid  fruit 
drops. 

Molasses,  Treacle,  and  Sirup. —  Molasses  and  treacle  are  products 
incidentally  formed  in  the  process  of  crystallizing  and  purifying  cane 
sugar.  Treacle  is  the  waste  drained  from  molds  used  in  the  refining 
process,  and  it  contains,  besides  sugar,  acids,  extractives,  salts,  and 
more  or  less  dirt.  Like  cane  sugar,  molasses  constitutes  a  very  de- 
sirable food,  and  is  highly  nutritious.  Its  use,  both  for  cooking 
and  to  add  to  farinaceous  food  and  enhance  its  flavor,  is  too  well 
known  to  require  description.  Molasses,  according  to  Konig,  con- 
tains acetic  and  formic  acids,  which  impart  their  reaction  to  it.  It 
also  contains  cane  sugar  and  30  per  cent  each  of  invert  sugar  and 
of  water. 

Both  treacle  and  molasses,  owing  to  impurities,  are  more  laxa- 
tive than  refined  sirup,  and  the  effect,  as  an  aperient,  of  plain  ginger- 
bread made  with  good  brown  molasses  is  due  to  this  property.  For 
young  children  from  six  to  ten  years  of  age  molasses  sometimes  oper- 
ates in  keeping  the  bowels  open. 

An  old-time  custom  among  soldiers  in  the  field  is  to  fill  a  canteen 
with  two  parts  vinegar  and  one  part  molasses  as  an  emergency  sus- 
taining drink. 

Glucose. —  Grape  sugar  is  present  in  almost  all  fruits,  in  the 
sweeter  varieties  of  which  it  exists  in  large  quantity.  In  peaches, 
pineapples,  and  strawberries  it  is  found  with  cane  sugar,  and  in 
grapes,  cherries,  and  honey  it  occurs  in  connection  with  other  varie- 
ties of  sugars.  In  dried  fruits,  such  as  raisins  or  figs,  glucose  is 


158         FOODS  AND  FOOD  PREPARATIONS 

present  in  a  gummy  form.     It  is  commonly  manufactured  from  starch. 

Although  prepared  for  immediate  absorption  from  the  stomach 
and  intestine  and  assimilation,  glucose  is  of  little  service  for.  fla- 
voring other  articles  of  food,  for  when  so  used  it  is  apt  to  produce 
flatulent  dyspepsia  with  acid  eructations. 

Sucrose  and  maltose  can  only  be  absorbed  by  alteration  into  glu- 
cose. If  glucose  be  eaten  as  a  food,  in  form  of  candy  or  otherwise, 
it  overloads  the  system  by  being  too  promptly  absorbed.  Malt  ex- 
tracts, sirups,  and  preserves  adulterated  with  glucose  easily  ferment 
with  the  bacteria  present  in  the  stomach. 

Lactose. —  Lactose,  or  sugar  of  milk,  is  taken  as  a  food  as  an  in- 
gredient of  ordinary  milk,  and  forms  a  very  important  part  of  the 
diet  of  the  growing  infant.  It  might  be  used  for  sweetening  various 
articles  of  food,  but  it  possesses  no  advantages  over  ordinary  cane 
sugar,  and  is  in  fact  more  expensive  and  less  sweet.  It  is  mildly 
diuretic.  It  may  be  given  to  typhoid  fever  patients  to  lessen  tissue 
waste. 

Mannite. —  Mannite  is  obtained  from  the  sweet  juice  of  the  stems 
of  the  ash  tree.  It  is  also  contained  in  beet  roots  and  some  other 
vegetables.  Like  sucrose,  it  crystallizes,  and  is  white  and  free  from 
odor.  It  does  not  ferment  with  yeast.  It  is  laxative,  and  may 
be  used  in  diabetes,  for  it  is  not  secreted  in  the  urine  as  glucose. 

Levulose. —  Fruit  sugar,  or  levulosc,  is  now  sold  under  the  name 
of  "  diabetin,"  in  crystalline  form,  for  use  in  diabetes,  on  the  ground 
that  it  is  not  known  to  reappear  in  the  urine.  It  may  be  taken  freely 
and  in  considerable  quantity  without  disordering  digestion,  as  sac- 
charin often  does  after  continued  use.  Diabetin  is  sweeter  than  cane 
sugar,  and  has  a  somewhat  fruity  taste. 

Honey. —  Honey  is  a  form  of  sugar  prepared  from  the  cane  sugar 
of  various  flowering  plants  gathered  by  bees,  which  convert  it  by 
hydrolysis  chiefly  into  dextrose.  They  then  store  it  in  cells.  Thus 
it  is  really  a  vegetable  product,  although  manufactured  by  an  insect. 
In  addition  to  sugar,  it  holds  several  other  ingredients,  principally 
wax,  gum,  pigment,  and  odorous  materials.  The  sugar  exists  in 
two  forms  —  crystallizable  and  non-crystallizable.  The  former  is 
somewhat  similar  to  glucose. 

Honey  contains,  according  to  Konig:  Water,  16.13;  dextrose, 
78.74;  cane  sugar,  2.69;  nitrogenous  matter,  1.29;  ash,  0.12  per  cent, 
beside?  traces  of  other  ingredients. 

IFonoy  was  more  in  demand  for  sweetening  before  the  discovery 
of  a  method  of  making  sugar  from  the  sugar  cane.  It  is  a  whole- 
some food,  and  is  fattening  when  eaten  with  bread.  In  some  coun- 


VEGETABLE   FOODS  159 

tries  —  as,  for  example,  in  the  Black  Forest  of  Baden  —  the  peasants 
consume  it  as  a  staple  article  of  diet.  Artificial  honeycombs  are 
now  made  from  paraffin,  stamped  into  cells  to  imitate  the  original, 
which  enables  the  bees  to  devote  more  energy  to  the  manufacture  of 
honey  and  bestow  less  on  the  combs. 

In  a  few  instances,  fortunately  very  rare,  honey  has  proved  poison- 
ous owing  to  the  bees  having  fed  upon  poisonous  flowers.  An  epi- 
demic of  gelsemin  poisoning  occurred  in  Branchville,  S.  C.,  from 
this  cause  in  which  twenty  persons  were  severely  affected,  three  of 
them  fatally.  The  poisoning  of  Greek  soldiers  by  honey  is  mentioned 
in  Xenophon's  Anabasis  (viii,  4). 

Saccharin. —  Saccharin  is  a  crystallizable  organic  acid  substance, 
containing,  in  addition  to  the  elements  carbon,  hydrogen,  and 
oxygen,  a  little  sulphur  and  nitrogen.  It  was  introduced  a  few  years 
ago  as  a  substitute  for  sugar,  and  it  is  especially  useful  in  cases  of 
obesity,  rheumatism,  gout,  and  diabetes,  when  the  withdrawal  of 
sugar  is  followed  by  intense  craving  for  it,  or  a  refusal  to  eat  those 
foods  which  are  customarily  iiavored  with  it.  It  is  antiseptic,  and 
has  the  property  of  acidifying  the  urine,  being  eliminated  unaltered 
by  the  kidneys.  It  may  be  given  for  months  at  a  time  without  danger, 
if  the  quantity  prescribed  does  not  exceed  more  than  one  or  two 
grains  three  times  a  day.  More  than  this  dose  may  cause  gastric 
derangement.  It  may  be  added  to  food  in  cooking,  and  a  one-quarter 
grain  tablet  may  be  used  to  sweeten  a  cup  of  coffee. 

Cereals  and  Other  Starch-bearing  Foods 

STARCH-BEARING   FOODS   IN    GENERAL, 

The  cereals  in  commonest  use  as  food  products  are  wheat,  corn, 
rice,  rye,  barley,  oats,  buckwheat.  From  these  are  manufactured  a 
variety  of  flours  and  meals. 

About  30  per  cent  of  all  cereals  produced  in  the  world  are  grown 
in  the  United  States,  and  at  least  one-fourth  of  the  total  wheat  pro- 
duction is  from  this  country;  on  the  other  hand,  98  per  cent  of  the 
rye  and  75  per  cent  of  the  barley  and  oats  are  grown  in  Europe. 
The  United  States  produces  about  75  per  cent  of  the  corn  of  the 
world.  These  estimates  give  a  general  idea  of  the  relative  use  of 
these  cereals,  and  illustrate  the  great  preponderance  of  wheat  bread 
and  cornmeal  and  other  preparations  of  corn  eaten  in  the  United 
States. 

Besides  the  cereals  and  vegetables  which,  like  the  potato,  are  com- 
posed chiefly  of  starch,  there  is  a  large  miscellaneous  group  of  starchy 


160 


FOODS  AND  FOOD  PREPARATIONS 


or  amylaceous  foods  used  as  flours,  which  are  therefore  conveniently 
considered  with  the  cereals.  Such  are  arrowroot,  tapioca,  cassava, 
sago,  and  peas.  Peanuts,  chestnuts,  and  plantains  are  also  sometimes 
used  to  furnish  flour. 

Starch  is  the  term  applied  to  the  fecula  or  granular  material 
found  in  fruits,  roots,  and  tubers  and  in  the  cellular  tissue  of  plants. 
The  structure  and  form  of  the  starch  granules  vary,  and  those 
from  different  plants  may  be  distinguished  by  microscopic  examina- 
tion. 

Patients,  as  a  rule,  are  ignorant  as  to  the  nature  and  limitations 
of  "  starchy  foods/'  and  their  conception  of  them  is  based  upon  such 
foods  as  resemble  powdered  laundry  starch  in  appearance,  like  ar- 
rowroot, cornstarch,  etc.  After  being  told  to  eat  no  starchy  foods, 
they  not  infrequently  will  say  they  suppose  that  potatoes  are  not 
starchy.  The  expression  at  best  is  not  an  accurate  one;  for  many 
starch-holding  foods  contain  a  large  proportion  of  other  ingredients, 
especially  proteids,  as  will  be  seen  from  the  following  table  by  C. 
F.  Langworthy. 

Composition  of  Cereal  Food   (Langworthy). 


Pro- 
tein. 

Fat. 

Carbo- 
hy- 
drates. 

Ash. 

Fuel 
value  per 
pound. 

Flour,  meal,  etc.: 
Entire-wheat    flour           

Percent. 
13.8 

13.3 

11.4 
13.4 
12.1 
6.4 
6.8 
9.2 
16.7 
8.0 
.4 

Percent. 

1.9 
2.2 

1.0 
.9 
1.8 
1.2 
0.9 
1.9 
7.3 
.3 
.1 

Percent. 
71:9 

71.4 

75.1 

74.1 
75.2 
77.9 
78.7 
75.4 
66.2 
79.0 
88.0 
90.0 

Percent. 

1.0 
1.8 

.5 
1.3 
1.3 
.9 
.7 
1.0 
2.1 
.4 
.1 

Cal. 

1,650 
1,645 

1,635 
1,645 
1,680 
1,605 
1,620 
1,&35 
1,800 
1,620 
1,650 
1,675 

1,200 
1,040 
1,195 
1,130 
1,170 
1,630 
1,925 
1,910 
1,875 

Graham   flour            

Wheat  flour,  patent  roller  process 
—  High-grade  and  medium    .  .  . 
Macaroni    vermicelli    etc  

Wheat  breakfast  food   

Buckwheat    flour    

Rve    flour     

Corn  meal                         

Oat   breakfast   food               

Tapioca- 

Starch     

Bread,   pastry,   etc.  : 
White  bread    

9.2 

5.4 
8.9 
9.7 
9.0 
6.3 
9.7 
11.3 
9.8 

1.3 
1.8 
1.8 
.9 
.6 
9.0 
12.1 
10.5 
9.1 

53.1 
47.1 
52.1 
49.7 
53.2 
63.3 
69.7 
70.5 
73.1 

1.1 
2.1 
1.5 
1.3 
1.5 
1.5 
1.7 
2.9 
2.1 

Brown  bread    

Graham  bread   

Whole-wheat   bread    

Rve   bread    

Cake    

Cream    crackers      

Oyster    crackers    

Soda  crackers    

VEGETABLE  FOODS 


161 


Farinaceous  foods  are  composed  of  flour  of  different  kinds,  and 
constitute  a  subdivision  of  starchy  foods.  The  different  starchy  and 
farinaceous  foods  are  derived  from  a  variety  of  plant  structures,  in- 
cluding roots,  tubers,  bulbs,  stems,  pith,  flowers,  seeds,  fleshy  fruits, 
etc.  Some,  like  the  banana  and  certain  vegetables,  are  eaten  raw, 
but  the  majority  require  cooking,  and  the  starches  derived  from 
grain-bearing  plants  of  the  grass  tribe  or  cerealia  usually  must  be 
prepared  by  grinding  and  milling  before  cooking.  About  one-sixth 
of  the  .  protein  of  the  various  grain  flours  passes  through  the  ali- 
mentary canal  undigested. 


Atwater's  Table  of  the  Percentage  of  Starch  in  Vegetable  Foods. 


Wheat  bread   55.5 

Wheat  .flour    75.6 

Graham  flour    71.8 

Eye  flour   78.7 

Buckwheat   flour    77.6 

Beans    57.4 

Oatmeal     68.1 

Cornmeal    71.0 

Rice     .  79.4 


Potatoes    21.3 

Sweet  potatoes    21.1 

Turnips     6.9 

Carrots     10.1 

Cabbage 6.2 

Melons    2.5 

Apples    14.3 

Pears 16.3 

Bananas                                        .  . .  23.3 


In  round  numbers  it  may  be  stated  that  starch  composes  one-fifth 
of  potatoes,  one-half  of  peas,  beans,  wheat,  rye,  and  oats  (their  flours 
contain  more),  and  three-fourths  of  rice  and  Indian  corn. 

In  addition  to  the  cooking  which  the  cerealia  require,  they  are 
often  predigested  by  diastase  for  invalid  use.  Strong  heat  converts 
starch  to  dextrin;  but  diastase,  like  the  natural  digestive  ferments, 
can  convert  it  into  maltose,  and  as  such  it  is  fitted  for  absorption. 

Fortified  gruels,  as  they  are  called  by  Eoberts,  are  made  of  cereal 
flours  or  dried  legumes,  with  addition  of  milk,  beef  tea,  or  eggs.  The 
flours  if  used  alone,  in  strength  of  5  per  cent,  become  pastry  and  are 
insipid,  but  if  one-eighth  of  their  weight  of  ground  malt  be  added 
they  remain  fluid  with  20  per  cent  of  flour,  and,  as  this  starch  is 
largely  dextrinized,  they  are  highly  nutritious.  Thus  made,  Eoberts 
says  they  contain  2  per  cent  of  protein  and  14  per  cent  of  carbo- 
hydrates. 

BREAD-MAKING 

It  has  been  well  said  that  the  quality  of  the  bread  used  by  the 
inhabitants  of  any  country  is  a  fair  measure  of  their  civilization. 
Flour  is  prepared  from  various  grains  by  crushing  and  grinding 
processes.  The  grains  consist  of  (1)  an  outer  layer,  the  husk  or 
skin,  which  is  woody,  fibrous,  and  indigestible,  and  which  in  the 
13 


162 


FOODS  AND  FOOD  PREPARATIONS 


milling  process  is  separated  into  "bran";  (2)  a  kernel  within  the 
husk,  which  is  composed  of  gluten,  fats,  and  salts;  (3)  starch. 

To  appreciate  the  important  details  of  bread-making,  it  will  be 
necessary  first  to  review  the  structure  and  composition  of  the  grain 
from  which  the  bread  is  derived. 

Structure  of  the  Wheat  Kernel. —  The  wheat  kernel  is  subdivided 
into  four  layers.  The  first  or  outermost  layer  (Fig.  25,  H)  consists 

of  two  or  three  strata  of  elongated  cells 
the  long  diameters  of  which  correspond 
with  the  long  axis  of  the  grain.  From 
these  cells  slender  filaments  or  tapering, 
hair-like  processes  project  outward.  The 
cell  margins  are  irregular  in  outline,  and 
appear  somewhat  beaded. 

Immediately  beneath  the  outer  hairy 
layer  lies  the  second  layer  (Fig.  25,  F), 
consisting  of  more  or  less  quadrangular 
cells,  with  rounded  angles,  which  are  more 
uniform  in  size  than  the  others,  and  grow 
at  right  angles  to  them.  The  third  layer 
(Fig.  25,  K]  consists  of  a  delicate,  trans- 
parent membrane-like  structure.  The 
fourth  or  internal  layer  (Fig.  25,  S)  is 
composed  of  large,  almost  rectangular 
cells  arranged  in  one  or  two  strata,  which 
contain  a  dark  granular  material  that  may 
be  separated  easily  from  the  cell  walls. 

The  grains  of  other  cereals  conform  in 

a  general  way  to  the  structure  of  the  wheat  grain,  although  they 
differ  in  the  thickness  of  the  several  layers,  the  number  of  their  strata, 
and  the  size  of  the  individual  cells. 

The  wheat  grain  contains  about  14  per  cent  of  proteids  (chiefly 
cerealin  and  gluten),  a  trace  of  sugar,  cellulose,  much  starch  (70  per 
cent)  fat  (2.60  per  cent),  and  ash  about  2  per  cent  (mainly  phos- 
phoric acid  and  potash).  The  remainder  is  water  (about  10  per  cent). 
Bran. —  Wheat  bran  contains  about  15  per  cent,  of  protein,  3.5 
per  cent  of  fattv  matter,  and  6  to  7  per  cent  of  mineral  substance, 
mainly  phosphates  (Yeo),  all  of  which  materials,  from  a  purely 
theoretical  standpoint,  should  be  nutritious,  but,  practically,  little 
bran  is  absorbed,  and  it  is  often  irritating,  especially  where  feeble- 
ness of  the  digestive  organs  exists.  As  proved  by  the  researches  of 
Professor  Snyder,  this  is  the  reason  why  bread  made  from  patent 


FIG.  25. —  SECTION  THROUGH 
WHEAT  KERNEL  ( From 
Rupp). 

H,  Hair-like  processes;  F, 
K,  second  and  third  lay- 
ers; S,  fourth  internal 
rectangular  cell  layer ; 
a,  b,  c,  d,  successive  lay- 
ers represented  as  par- 
tially stripped  off. 


VEGETABLE  FOODS 


163 


flours  is  so  much  more  digestible  than  that  made  from  Graham  or 
whole  wheat  flour. 

Gluten. —  Gluten  is  separated  in  the  process  of  making  starch  from 
wheat  and  other  grains.  It  is  a  valuable  proteid  consisting  of  (a) 
60  to  70  per  cent  gliadin  and  (6)  30  to  40  per  cent  glutenin.  The' 


FIG.  26. —  CROSS  SECTION  OF  A  GRAIN  OF  WHEAT  AS  SEEN 

UNDER  THE  MICROSCOPE. 
(U.  S.  Dept.  of  Agri.,  Bui.  56,  Office  of  Expt.  Stations.) 

greater  part  of  the  gluten  is  held  in  the  central  four-fifths  of  the 
grain.  The  gliadin  adheres  to  the  glutenin,  retains  the  gas  in  dough, 
and  in  excess  it  makes  the  flour  soft  and  sticky,  hence  soft  wheat 
yields  a  flour  with  high  percentage  of  gliadin,  but  hard  wheat  has 
a  low  percentage. 

Gluten  is  capable  of  considerable  expansion  independently  of  the 


164 


FOODS  AND  FOOD  PREPARATIONS 


FIG.  27. —  MICROSCOPIC  CHARACTERS  OF 
WHEAT  (+  200)  (From  Landois  and 
Stirling). 

a,  cells  of  the  bran;  b,  cells  of  thin 
cuticle;  c,  gluten  cells;  d,  starch 
cells. 


development  of  C02,  and,  as  this  power  varies  with  different  flours, 
it  affects  the  quality  of  lightness  of  the  bread.  When  pure  it  is  so 
adhesive  as  to  admit  of  being  drawn  into  long  shreds  or  bands,  as  in 
"shredded  wheat." 

Composition  of  Bread. —  Bread  is  really  a  mixed  food,  in  that  it  con- 
tains so  many  classes  of  ingredients^ — fat,  protein,  salts,  sugar,  and 
starch  —  and  this  is  probably  the  explanation  of  the  fact  that  its 

-i  a  daily  use  never  cloys  the  ap- 
petite. Although  it  contains 
some  fat,  it  has  not  enough 
for  a  perfect  food,  and  hence 
the  almost  universal  custom 
of  using  butter  with  it. 
Moreover,  it  forms  a  conven- 
ient vehicle  for  taking  fat  in 
this  manner,  and  the  butter 
aids  in  the  mastication  and 
deglutition  of  the  bread. 

In  round  numbers,  bread 
contains  about  two-thirds  nu- 
trient material,  or  twice  as  much  as  beef,  although  it  is  of  different 
force  value  in  the  body.  One  hundred  grams  (3i/^  ozs.)  furnish  216 
calories. 

Bread-baking. —  Bread  is  made  from  a  mixture  of  the  flour  of 
any  cereal  with  water,  constituting  a  dough  which  is  made  uniform 
by  kneading  either  by  hand  or  by  machinery.  A  pound  of  bread  is 
made  from  about  three-quarters  of  a  pound  of  flour  by  the  addition 
of  25  per  cent  of  water.  Some  flours  will  take  up  10  per  cent  more 
water.  A  small  quantity  of  the  ferment  yeast  is  also  worked  uni- 
formly into  the  dough  with  a  little  salt  and  the  mass  is  left  to 
stand  for  a  number  of  hours,  during  which  fermentation  progresses, 
producing  from  the  starch  alcohol,  carbonic  acid,  and  water.  The 
best  temperature  at  which  this  leavening  proceeds  is  from  100°  to 
110°  F.  After  remaining  for  some  hours  at  this  uniform  tempera- 
ture, the  bread  is  baked  in  a  hot  oven  the  temperature  of  which  is 
sufficient  to  kill  the  yeast  germs  and  check  further  fermentation. 

Of  all  the  cooking  processes  now  in  use  by  civilized  man,  the 
making  of  bread  is,  perhaps,  the  most  important.  The  object  of 
cooking  flour  in  this  manner  is  to  make  it  light  and  porous,  so  that 
the  digestive  fluids  may  be  incorporated  easily  with  it.  Flour  eaten 
alone  forms  a  glutinous  or  sticky  mass  which  is  quite  indigestible 
and  difficult  to  swallow,  besides  being  comparatively  tasteless.  There 


VEGETABLE  FOODS 


165 


are  many  variations  in  the  process  of  bread-making,  but  all  are 
based  upon  the  same  principle  —  the  development  of  carbonic-acid 
gas  throughout  the  mass  of  dough,  which  bubbles  up  and  causes  it 
to  "  rise  "  or  forces  it  apart.  In  general,  the  process  involves  a  loss 
of  about  1  per  cent  of  C02  and  1  per  cent  of  alcohol.  The  loss  of 
volatile  products  represents  a  loss  of  but  1.58  per  cent  of  starch. 
Of  the  remaining  starch  less  than  8  per  cent  is  converted  into  soluble 
form  (dextrin),  but  many  of  the  starch  granules  are  ruptured  or  dis- 
integrated. 

Development   of   Carbonic-acid  Gas. —  Carbonic-acid   gas   may  be 


FIG.  28. —  YEAST  PLANT  —  TORULA  CEREVISICE  —  MAGNIFIED. 
(U.  S.  Dept.  of  Agri.,  Bui.  56,  Office  of  Expt.  Stations.) 

generated  or  introduced  in  four  ways:  I.  Indirectly  by  natural  fer- 
mentation excited  by  the  addition  of  the  yeast  fungus,  Torula  or 
Saccharomycetes  cerevisice.  II.  By  the  use  of  "  leaven,"  a  name  given 
to  old  dough  in  which  fermentation  has  already  occurred.  III.  By 
the  addition  of  baking  powders.  IV.  Directly  by  "  aeration/' 

I  and  II.  Bread  Made  by  Yeast  or  Leaven. —  When  bread  is  made  by 
yeast  or  leaven  the  process,  which  may  be  divided  into  three  stages, 
is  as  follows: 


166         FOODS  AND  FOOD  PREPAEATIONS 

(1)  Kneading  the  flour  thoroughly,  to  mix  the  water,  yeast  and 
salt. 

(2)  Fermentation  with  moderate  heat,  during  which  the  accumu- 
lating carbonic-acid  gas  endeavors  to  escape  in  bubbles,  which  become 
entangled  in  the  more  or  less  tenacious  gluten  of  the  flour.     Upon 
the  size  and  number  of  these  bubbles  depends  the  porosity  of  the 
bread,  and  this  in  turn  is  modified  somewhat  by  the  kind  of  flour 
used,  the  quantity  of  the  ferment,  and  the  rapidity  with  which  the 
development  of  carbonic  acid  is  allowed  to  proceed. 

(3)  Baking  the  dough,  during  which  the  heat  of  the  oven,  by 
expanding  the  carbonic-acid  gas,  makes  the  bread  still  more  porous 
and  "  sets  "  the  walls  of  the  little  cavities  which  have  formed  so  that 
the  loaf  maintains  its  shape.     The  gas  is  finally  driven  off,  together 
with  a  large  quantity,  but  not  all,  of  the  water,  which  escapes  in  part 
through  evaporation,  when  the  external  portion  of  the  bread  becomes 
drier  and  browner  than  the  interior  or  crumb,  and  constitutes  the 
crust.     The  thickness  of  the  crust  will  depend  upon  the  character 
of  the  flour  used,  the  temperature  of  the  oven,  and  the  duration  of 
the  process  of  baking. 

With  the  exception  of  these  changes,  bread  has  practically  the 
same  composition  as  its  original  flour. 

Mixing  meal  or  flour  with  fat  tends  to  prevent  the  evaporation 
of  water  from  the  bread. 

The  chief  art  in  baking  bread  consists  in  arresting  the  yeast  fer- 
mentation of  the  dough  by  the  heat  of  the  oven  (300°  to  400°  F.)  at 
exactly  the  right  period.  If  fermentation  has  not  proceeded  far 
enough  the  bread  is  tough,  or  sodden,  or  lumpy,  whereas  if  it  has 
gone  too  far  it  acquires  a  sour  taste  by  the  development  from  the 
carbohydrates  of  organic  acids,  such  as  acetic,  butyric,  and  lactic, 
which  are  both  unpalatable  and  unwholesome.  Fermentation  pro- 
duced by  the  use  of  leaven  instead  of  yeast  is  much  more  difficult  to 
control,  and  these  acids,  therefore,  are  more  likely  to  be  formed.  The 
bread  made  with  fresh  brewers'  yeast  is  by  many  esteemed  to  have 
the  best  flavor.  There  are  several  minor  chemical  changes  described 
by  H.  Snyder  and  L.  A.  Yoorhees : 

"  (1),  the  formation  of  volatile  carbon  compounds;  (2),  a  change 
in  the  solubility  of  the  protein  compounds;  (3),  the  formation  of 
amid  and  ammonium  compounds  from  soluble  proteids;  and  (4),  the 
partial  oxidation  of  the  fat." 

About  2  per  cent  of  the  weight  of  the  flour  used  is  lost  in  volatil- 
izing these  various  organic  products.  "With  prolonged  fermentation 
this  loss  may  amount  to  8  per  cent. 


VEGETABLE   FOODS  167 

In  steam-cooked  cereals  also,  the  starch  is  partially  dextrinized  and 
thus  rendered  more  digestible. 

III.  Baking   Powders. —  Carbonic-acid  gas   may  be   developed   in 
bread  by  the  action  of  baking  powders.     These  powders  are  very  ex- 
tensively employed,   and   "  a  conservative   estimate   of  the  quantity 
of  baking  powder  used  in  the  United  States  each  year  places  the 
figure  considerably  above  50,000,000  pounds"  (Clark). 

There  has  been,  however,  much  argument  in  regard  to  their 
wholesomeness,  and  elaborate  researches  in  chemistry  and  the  phys- 
iology of  digestion  have  been  conducted  to  determine  whether  or 
not  the  continued  use  of  these  ingredients  in  bread  is  injurious.  The 
so-called  baking  powders  are  manufactured  by  the  combination  of 
many  different  ingredients,  such  as  sodium  carbonate  with  tartaric 
acid,  the  acid  phosphate  of  lime  with  sodium  carbonate  and  potas- 
sium chloride  (Liebig-Horsford),  or  a  combination  may  be  used  of 
ammonium  carbonate  with  hydrochloric  acid.  It  is  claimed  by  the 
advocates  of  the  use  of  baking  powders  that  they  possess  many  ad- 
vantages, such  as  the  fact  that  the  bread  rises  quicker,  and  that  al- 
though fermentation  does  not  occur,  the  bread  is  more  porous,  and 
-hence  more  digestible,  and  that  its  taste  is  not  impaired.  On  the 
other  hand,  it  is  argued  that  such  bread,  especially  when  am- 
monium carbonate  is  employed,  in  time  may  excite  dyspepsia  and 
gastric  catarrh.  Even  when  not  used  for  the  making  of  bread  these 
baking  powders  often  are  employed  in  the  preparation  of  various 
forms  of  cake  where  lightness  and  quickness  in  making  are  important 
features. 

Baking  powder  when  pure  should  consist  only  of  cream  of  tartar 
(acid  tartrate  of  potash,  obtained  as  a  precipitate  in  the  casks  in  which 
wine  is  made)  and  soda,  with  a  little  flour  added,  and  should  be  free 
from  alum,  ammonia,  etc.  Mixed  with  water  and  dough,  the  soda 
is  split  by  the  acid  tartrate,  liberating  carbonic-acid  gas.  Alum  is 
sometimes  used  in  baking  powders  with  soda.  Its  action  is  less  re- 
liable, and  in  large  quantities  it  is  astringent  and  injurious  to  di- 
gestion. 

IV.  Aerated  Bread. —  The   process  of  aerating  bread  consists  in 
the  forcing  of  carbonic-acid  gas  into  the  dough  under  pressure.     The 
gas  is  generated  by  the  action  of  sulphuric  acid  upon  lime,  and  while 
there  are  several  methods  of  its  use,  in  general,  about  one  cubic  foot 
of  gas  is  applied  to  fourteen  pounds  of  flour,  although  not  over  one- 
half  of  this  quantity  remains  in  the  dough.     It  is  claimed  for  this 
process  that  the  bread  is  exceptionally  light,  dry,  and  porous,  that 
there  is  no  danger  of  malfermentation,  with  production  of  acidity, 


168         FOODS  AND  FOOD  PREPARATIONS 

and  that  it  sooner  hardens  when  exposed  to  the  air  as  compared  with 
home-made  bread  prepared  with  yeast. 

Aerated  bread  keeps  fresh  longer  than  other  varieties.  It  yields  a 
peculiar  flavor  which,  however,  is  preferred  by  some  people.  It  is 
claimed  as  a  further  advantage  for  its  manufacture  that  the  bread 
requires  less  kneading  by  the  sometimes  dirty  hands  of  the  baker. 
Some  twenty  or  thirty  varieties  of  germs  are  usually  to  be  found 
beneath  the  finger  nails  of  persons  who  are  ordinarily '  cleanly.  If 
special  care  is  not  taken  by  those  who  prepare  bread  it  is  possible 
for  disease  germs  to  be  introduced  from  beneath  the  nails  into  the 
dough.  It  has  been  claimed  that  various  infectious  diseases  might 
be  transmitted  in  this  manner.  The  danger,  aside  from  any  aesthetic 
consideration,  is,  however,  grossly  exaggerated,  as  the  fermentative 
processes,  together  with  the  prolonged  heat  used  in  baking,  are  fatal 
to  both  germs  and  spores. 

In  aerated  bread  salt  is  added  to  the  dough  as  in  the  other 
processes,  with  the  result  of  making  the  bread  firmer  and  somewhat 
whiter. 

There  are  many  cereals,  such,  for  example,  as  oatmeal  and  the 
coarser  whole  meals,  which  are  exceedingly  wholesome  when  cooked 
by  some  methods,  but  which  cannot  be  baked  into  'good  bread  be- 
cause of  the  difficulty  of  making  them  porous,  and  their  attempted 
use  in  this  form  usually  results  in  dyspepsia,  with  heartburn  and 
acid  fermentation. 

The  addition  of  boiled  rice  flour  in  bread-making  causes  the  bread 
to  become  more  adhesive  and  to  hold  more  water.  Hence  bakers 
sometimes  resort  to  this  means  to  make  their  bread  heavier  when  it  is 
sold  by  weight. 

Freshly  baked  bread  is  less  digestible  than  dry  bread  for  the  reason 
that,  being  more  moist,  it  tends  to  form  a  tenacious  bolus  in  the 
mouth  which  is  not  readily  mingled  with  the  saliva  or  other  di- 
gestive secretions.  Dry  bread,  on  the  other  hand,  crumbles  into 
smaller  particles,  which  are  easily  acted  upon  by  the  saliva  and 
pancreatic  juice.  For  the  same  reason,  the  crust  of  bread  is  more 
digestible  than  the  interior  part  of  the  loaf. 

Spoiled  Bread.— Bread  may  be  unfit  for  use  from  being  made  of 
adulterated  or  too  old  flour,  from  turning  sour  from  bad  flour  de- 
veloping excess  of  lactic  acid,  from  becoming  bitter  from  yeast,  from 
becoming  sodden  from  insufficient  fermentation  or  aeration,  and  it 
may  grow  moldy  from  exposure  to  warm  and  damp  air  when  it  is  too. 
moist. 


VEGETABLE   FOODS  169 

VARIETIES  OF  BREADSTUFFS  AND  PREPARED  FARINACEOUS  FOODS 

Wheaten  Flour  and  Bread. —  Bread  of  different  kinds  constitutes 
the  staple  starchy  food  for  Americans,  as  the  potato  does  for  the 
Irish  peasantry  and  macaroni  for  the  Italians. 

The  quantity  of  bread  consumed  varies  somewhat  with  the  ability 
to  obtain  other  articles  of  diet.  For  example,  persons  residing  in 
large  cities  are  wont  to  eat  a  larger  percentage  of  animal  food  and 
less  breadstuff  than  those  in  the  country.  The  French  laborer  con- 
sumes  daily  eight  hundred  grams  (nearly  two  pounds)  of  bread 
in  the  country  against  five  hundred  in  the  city. 

Tough,  moist,  imperfectly  baked,  or  hot  bread,  is  liable  to  ex- 
cite further  fermentation  in  the  stomach,  causing  heartburn  and  other 
symptoms  of  dyspepsia.  The  digestibility  of  such  bread  is  promoted 
by  heating  it  to  drive  off  the  moisture,  and  by  spreading  it  well  with 
butter  to  prevent  it  from  agglutinating  in  the  stomach. 

Water  continues  to  evaporate  from  hot  fresh  bread,  and  such 
bread  should  not  be  covered  tightly,  or  else  it  becomes  sodden. 

Stale  bread  is  more  digestible  than  fresh  bread.  In  stale  bread 
water  is  evaporated  to  a  great  extent,  so  that  the  bread  becomes 
friable  and  is  more  readily  masticated  and  mingled  with  digestive 
fluids.  The  fact  that  stale  bread  on  being  warmed  over  becomes 
softer  is  accounted  for  on  the  hypothesis  that  in  drying  the  water 
has  not  all  been  evaporated,  but  that  some  of  it  has  combined  with 
the  flour,  forming  a  new  compound,  which  is  dissociated  by  the  further 
application  of  heat  (Yeo). 

Toast  is  bread  sterilized  and  browned  by  heat  of  about  170°  C. 
(338°  F.).  The  additional  caramel  flavor  and  dryness  thus  acquired 
lessens  the  time  of  digestion  of  toasted  as  compared  with  fresh  bread  by 
one-third,  but  in  healthy  stomachs  the  digestion  of  toast  although 
quicker  is  on  the  whole  less  complete,  because  the  proteids  are  rendered 
less  soluble  by  2.5  per  cent.  The  heat  evaporates  the  water  of  the 
bread  and  changes  a  superficial  portion  of  the  starch  to  dextrin,  but  in 
artificial  digestion  experiments  the  carbohydrates  of  bread  and  toast 
are  equally  digestible.  (H.  Snyder,  Minnesota  Agricultural  Experi- 
ment Station  Eeports.)  A  slice  of  bread,  if  cut  sufficiently  thin, 
toasts  dry  and  crisp  throughout,  but  if  thick,  the  outer  layers  are 
scorched  while  the  mass  within  may  become  softer  than  before 
toasting. 

Buttered  dry  toast  is  a  digestible  form  of  invalid  food,  for  if  the 
butter  be  spread  thin  while  the  toast  is  quite  hot  it  penetrates  to  the 
interior,  and  both  fat  droplets  and  starch  crumbs  mutually  protect 
14 


170 


FOODS  AND  FOOD  PREPARATIONS 


each  other  from  cohering  in  large  masses.  The  butter,  moreover, 
enables  one  to  eat  more  bread  in  this  form.  The  same  is  true  of 
milk  toast,  which  furnishes  in  addition  a  means  of  giving  considerable 
milk  to  patients  who  are  unwilling  to  drink  it. 

Whole-meal  Bread. —  For  some  flours  the  whole  of  the  wheat  is  used, 
the  gluten,  nitrates  and  phosphates  all  being  retained. 

The  proportion  which  the  elements,  carbon  and  nitrogen,  bear  to 
each  other  is  such  that  wheaten  bread  alone  is  not  an  economical 
food.  If  man  is  to  live  upon  it  alone  for  any  length  of  time,  brown 
bread  or  Graham  bread  is  better  than  the  varieties  made  from  fine 


FIG.  29. —  BREAD  MADE  FROM  DIFFERENT  KINDS  OF  FLOUB, 

A,  307.7  Grams  of  bread  from  227  grams  of  graham  flour; 

B,  302.5  grams  of  bread  from  227  grams  of  entire  wheat  flour; 

C,  301.5  grams  of  bread  from  227  grams  of  standard  patent  flour. 

(U.  S.  Dept.  of  Agri.,  Bui.  101,  Office  of  Expt.  Stations.) 

flour,  from  which  latter  the  nitrogenous  elements  largely  have  been 
removed  by  milling.  A  " bread-and-water  diet"  is  proverbially  a 
reducing  diet,  and  as  such  it  is  given  to  insubordinate  prisoners  (see 
Diet  in  Prisons),  but  they  cannot  subsist  upon  it  for  longer  than 
two  or  three  weeks  at  most. 

Bread  made  of  whole  meal  is  usually  not  so  light  as  that  made 
with  refined  white  flour.  The  explanation  of  this  is  said  to  be  the 
fact  that  the  silieious  envelope  of  the  grain  contains  a  ferment  resem- 
bling diastase,  which  is  called  "  cerealin."  While  the  dough  is  rising, 
this  ferment  acts  upon  a  large  portion  of  the  starch,  forming  viscid 


VEGETABLE   FOODS  171 

compounds  of  dextrin  and  sugar,  which  by  agglutination  prevent  the 
carbonic-acid  gas  from  puffing  up  the  bread  as  much  as  it  should. 
On  the  other  hand,  too  much  attrition  in  the  mill  ruptures  the  indi- 
vidual starch  granules,  and  without  the  use  of  artificial  baking 
powders  the  bread  will  not  be  light  and  wholesome. 

The  British  Commissioners  of  Prisons  recommended  the  use  of 
whole-meal  bread  for  convicts  at  hard  labor  on.  account'  of  its  greater 
cheapness  and  nutritive  value,  but  advised  a  modification  in  the  proc- 
ess of  its  manufacture.  The  dough  is  made  of  flour  from  which  the 
sharps,  etc.,  have  been  removed.  The  latter  are  then  added  and 
mixed  thoroughly  with  the  dough  just  before  it  is  ready  for  baking, 
and  it  is  claimed  for  this  process  that  there  is  not  time  for  the  cerea- 
lin  to  act,  and  consequently  the  bread  is  much  lighter. 

For  economical  or  other  reasons,  wheaten  flour  is  sometimes  ad- 
vantageously mixed  with  potatoes  or  bean  flour.  The  latter,  added 
in  the  proportion  of  1  part  to  10  of  wheat,  gives  a  white  bread 
rich  in  nitrogen  and  highly  nutritious.  Corn  flour  may  be  mixed  in 
the  same  proportion. 

Pumpernickel  is  a  German  black  bread  made  with  unbolted  meal 
and  sour  dough.  It  is  somewhat  laxative. 

Zwieback  is  a  thoroughly  dry  form  of  aerated  bread,  which  is  very 
wholesome  for  invalids. 

Graham  bread  —  so  called  after  Sylvester  Graham,  who  advocated 
its  use  —  differs  from  white  bread  by  containing  bran.  The  bran, 
however,  while  containing  serviceable  proteid  and  phosphates  is  so 
difficult  of  digestion  that  it  tends  to  irritate  the  mucous  membrane 
of  the  intestine  and  increase  peristaltic  action.  For  this  reason  it 
is  more  laxative  than  white  wheat  bread. 

It  is  a  popular  idea  that  coarse  bread,  black  bread,  whole-meal 
bread,  etc.,  are  more  nutritious  than  the  bread  made  from  refined 
white  wheaten  flour  or  delicate  French  breads.  This  is  not  neces- 
sarily true,  and  much  depends  upon  the  digestive  organs  of  the  in- 
dividual. In  a  report  on  the  digestibility  and  nutritive  value  of 
bread  (Bulletin  No.  85,  U.  S.  Department  of  Agriculture)  by  Charles 
D.  Woods  and  L.  H.  Merrill,  they  show  the  coefficient  of  digestibility 
of  white  bread  averages  93.37  per  cent  (in  some  samples  it  is  as 
high  as  97.06  per  cent),  whereas  that  of  whole-wheat  bread  is  91.50 
per  cent,  and  that  of  Graham  bread  is  only  86.94  per  cent.  About 
87  per  cent  of  the  protein  is  absorbed.  They  also  found  that  bread 
was  rendered  more  digestible  when  eaten  with  milk  than  if  eaten 
alone,  the  increase  in  digestibility  amounting  to  15  per  cent.  There 
are  peasants  in  Europe  who  can  thrive  upon  the  coarsest  forms  of 


172 


FOODS  AND  FOOD  PREPARATIONS 


sour,  black  bread,  and  there  are  others  who  can  use  different  forms 
of  fermenting  foods  and  beverages  which  to  those  unaccustomed  to 
them  would  prove  most  injurious. 

According  to  Bauer,  "  with  wheaten  bread,  rice,  macaroni,  .etc., 
the  carbohydrates  are  utilized  to  within  0.8  or  1.6  per  cent,  whereas 
of  black  bread,  potatoes,  and  the  like,  8  to  18  per  cent  of  the  carbo- 
hydrates are  passed  with  the  feces." 

Decorticated  flour  is  prepared  by  special  methods  of  grinding  with 
the  object  of  removing  two  or  three  of  the  outermost  and  toughest 
coverings  of  the  grain,  but  not  the  inner  envelope.  Yeo  says  of 


B 


C 


FIG.  30. —  BREAD  MADE  FROM  ENTIRE  WHEAT,  PATENT,  AND  GRAHAM  FLOUBS, 
AND  CHARACTER  OF  FECES  FROM  SAME. 

A,  Feces  from  graham  bread; 

B,  feces  from  entire  wheat  bread; 

C,  feces  from  standard  patent  bread. 

(U.  S.  Dept.  of  Agri.,  Bui.  101,  Office  of  Expt.  Stations.) 

broad  made  from  such  flour,  that  while  it  may  be  suitable  "for 
young  and  growing  persons  with  sound  and  active  digestion,"  it  may 
"  prove  very  indigestible  to  adults  leading  sedentary  lives.  It  makes 
a  bread  which  is  usually  heavier,  moister,  and  of  closer  texture  than 
that  made  from  the  finest  wheat  flour." 

AVhen  digestion  is  not  vigorous,  it  is  better  to  obtain  the  neces- 
sary nitrogenous  material  from  animal  sources.  The  special  uses  of 
coarse  forms  of  bread  will  be  pointed  out  under  the  Treatment  of 
Constipation. 

Gluten   Bread. —  P>read    made   from   gluten   flour   is   useful   where 


VEGETABLE  FOODS  173 

there  is  a  tendency  to  obesity,  and  is  given  to  diabetics,  although 
with  less  benefit  than  has  been  claimed  for  it.  (See  Diabetes.) 
It  may  be  toasted  like  ordinary  bread.  The  best  bread  of  this  kind 
is  made  in  Paris,  and  contains  from  40  to  50  per  cent  of  gluten,  but 
there  are  many  so-called  gluten  breads  in  market  which  do  not 
contain  above  16  per  cent  of  gluten,  the  remainder  being  starch. 

Poluboskos  is  a  gluten  food  which  is  said  by  those  interested  in  its 
manufacture  to  contain  only  0.4  per  cent  of  starch.  The  name  indi- 
cates "much  nourishment."  It  is  given  to  diabetics  in  doses  of  one 
or  two  teaspoonfuls  in  milk. 

Biscuits,  Pastry,  Puddings,  etc. —  In  addition  to  bread  an  almost 
innumerable  variety  of  biscuits,  cakes,  pastry,  tarts,  pies,  etc.,  are 
prepared  by  the  addition,  in  various  proportions,  of  flour,  milk, 
cream,  butter,  or  other  fat,  sugar,  eggs,  flavoring  extracts,  and  fruit, 
such  as  raisins. 

For  making  pastry,  cake,  and  puddings  of  different  kinds,  the 
finer  grades  of  wheat  flour  usually  are  employed,  although  corn  and 
Indian  meal  are  sometimes  used. 

The  dough  is  raised  in  such  preparations  by  the  help  of  yeast, 
alcohol,  fat,  baking  powders,  or  whipped  white  of  egg.  A  hot  fire 
is  used  in  the  cooking,  and  the  puddings  are  either  baked,  boiled,  or 
steamed,  so  that  the  flour  is  altered  by  the  heat  in  much  the  same 
manner  as  in  the  manufacture  of  bread. 

These  foods  vary  so  much  in  richness  and  digestibility  that  it  is 
difficult  to  formulate  any  definite  rules  for  their  use.  In  general, 
they  should  be  avoided  by  persons  having  indigestion,  dyspepsia,  or, 
in  fact,  any  severe  illness;  but  farinaceous  puddings,  like  rice  or 
farina,  simply  made  and  thoroughly  cooked,  with  the  addition  of  eggs 
and  milk,  play  an  important  part  in  hospital  dietaries,  and  are  very 
good  foods  for  convalescents. 

Boiled  or  steamed  puddings,  being  unfermented  and  surrounded 
with  abundant  water,  are*  very  likely  to  be  sodden  or  stringy,  and 
therefore  indigestible. 

Pastry,  even  when  light,  is  apt  to  be  too  rich,  and  if  not  well 
cooked  it  is  sodden  or  tough  and  almost  certain  to  disagree,  mainly 
because  of  the  changes  which  the  high  grade  of  heat  produces  in  the 
butter  or  other  fats  used  in  its  preparation. 

Prepared  Farinaceous  Foods  (often  called  "  Infant  Foods,"  "  Pre- 
pared Baby  Foods  "  or  "  Proprietary  Foods  "). —  Prepared  farinaceous 
foods  are  made  by  the  following  methods:  1.  Application  of  heat 
alone.  2.  Digestion  with  malt  or  diastase  combined  with  heat.  3. 
After  dextrinization,  the  food  is  evaporated  with  milk  or  cream. 


FOODS  AND  FOOD   PREPARATIONS 

The  prepared  farinaceous  foods  may  be  eaten  alone  or  diluted 
with  water,  but  they  are  usually  given  to  invalids  in  a  cup  of  broth 
or  beef  tea,  which  disguises  their  sweetness.  The  sweeter  varieties 
are  combined  best  with  milk. 

1.  Farinaceous  Foods  Prepared  by  Heat  Alone. —  Imperial  Gran- 
um,  Flour  ball,  Eidge's  Food,  Blair's  Wheat  Food,  Schumacher's 
Food,  and  Robinson's  Patent  Barley  are  examples  of  this  class. 

Wheat  and  oats  are  sometimes  prepared  by  roasting  (not  steam- 
ing), a  process  which  removes  all  moisture  besides  producing  some 
chemical  changes  in  the  fats  and  starches.  Cereals  treated  in  this 
manner  will  keep  from  molding  in  any  climate,  and  are  both  diges- 
tible and  nutritious. 

Imperial  Granum  is  a  type  of  a  large  class  of  prepared  foods, 
the  basis  of  which  is  starch,  modified,  it  is  claimed,  so  as  to  render 
it  easily  digestible.  Such  foods  are  often  fed  to  newborn  infants 
to  the  exclusion  of  milk,  but  no  greater  mistake  can  be  made,  for  their 
digestive  apparatus  is  unfit  to  deal  with  very  much  starch.  The 
human  infant  is  designed  to  be  nursed  at  the  breast  for  the  first 
year  of  life,  and  Xature  has  furnished  ample  food  for  it  which  is 
wholly  devoid  of  starch.  The  saliva  and  pancreatic  secretion  upon 
which  the  digestion  of  starches  depends  are  not  adapted  fully  for 
this  work  during  the  first  eight  or  nine  months  of  life,  and  then 
only  partially,  hence  starchy  foods,  "farinaceous  baby  foods,"  should 
seldom  be  given  before  that  age  as  foods,  and  used  very  sparingly, 
if  at  all,  as  mechanical  diluents  of  milk.  Moreover,  in  such  simple 
starchy  foods  as  arrowroot  the  proportion  of  tissue-building  to  heat- 
producing  foods  is  one  to  twenty,  whereas  in  human  milk  it  is  one 
to  five. 

Granum  is  composed  of  over  three-fourths  starch,  made  into  a 
fine  flour.  One  tablespoonful  of  it  should  go  to  each  three  ounces  of 
water,  in  which  it  is  boiled  for  ten  minutes.  An  equal  quantity  of 
milk  is  then  to  be  added,  and  the  mixture  again  boiled  for  five  min- 
utes. It  is  a  useful  temporary  food  for  adults  with  irritable  stomachs. 
Flour  ball  is  prepared  by  boiling  wheat  flour  tied  in  a  bag,  with 
the  supposed  purpose  of  converting  it  into  dextrin,  and  it  is  a  popular 
belief  that  this  conversion  is  quite  complete;  but  it  requires  a  tem- 
perature of  250°  F.  to  clextrinize  starch,  and  this  degree  cannot  be  at- 
tained by  the  process.  Leeds  has  shown  that  after  seventy-five 
hours  of  continuous  boiling  the  percentage  of  soluble  carbohydrates 
is  increased  l>y  only  0.05  of  1  per  cent,  whereas  some  of  the  pre- 
pared foods  contain  from  two  to  six  times  as  much  soluble  carbo- 
hydrates as  wheat  flour.  Flour  ball  tastes  flat  and  insipid,  owing 


VEGETABLE  FOODS  175 

to  the  long  boiling  dissolving  out  fat,  soluble  albuminoids,  and  salts. 

Starr  gives  the  following  rule  for  the  making  of  flour  ball : 

Tie  one  pound  of  unbolted  wheat  flour  firmly  in  a  pudding  bag 
and  boil  for  ten  hours.  At  the  end  of  this  time  it  will  be  found,  on 
opening  the  bag,  that  the  outer  layer  of  the  ball  is  doughy,  while  the 
interior  is  hard  and  dry,  it  having  been  baked  by  the  long-continued 
heat.  This  hard  mass  may  be  used  for  infant  feeding  in  the  latter 
part  of  the  first  year,  but  it  should  not  be  given  more  than  twice  a 
day.  The  flour  ball  is  grated  fine,  and  it  may  then  be  prepared, 
according  to  Starr's  rule,  as  follows :  "  Eub  one  teaspoonful  of  the 
powder  with  a  tablespoonful  of  milk  into  a  smooth  paste,  then  add  a 
second  tablespoonful  of  milk,  constantly  rubbing  until  a  cream-like 
mixture  is  obtained.  Pour  this  into  eight  ounces  of  hot  milk,  stirring 
well,  and  it  is  then  ready  for  use.  The  flour  ball  thus  prepared  is 
quite  digestible,  and  prevents  the  formation  of  large  curds  of  milk. 
As  a  diluent  of  milk  it  is  much  cheaper  for  the  poor  than  the  pre- 
pared amylaceous  foods  which  are  on  sale. 

2.  Farinaceous  -foods  digested  with  malt  or  diastase  with  heat  are 
often  called  "  Liebig's  Foods." 

Liebig's  foods  are  made  of  equal  quantities  of  wheat  flour  and 
barley  malt,  with  bran,  and  1  per  cent  of  bicarbonate  of  potassium. 
These  ingredients  are  mixed  into  a  paste  with  water  and  digested 
for  several  hours  at  fixed  temperatures,  until  the  starch  is  trans- 
formed into  soluble  carbohydrates,  maltose,  and  dextrin.  The  food 
is  strained,  pressed,  and  extracted'  with  warm  water,  evaporated, 
dried,  and  pulverized,  when  it  is  ready  for  use. 

Liebig's  Infant  Food  is  a  good  illustration  of  this  type.  It  is  pre- 
pared as  follows: 

Mix  a  half  ounce  each  of  ground  malt  and  wheat  flour,  seven 
and  one-fourth  grains  of  potassium  bicarbonate  with  one  ounce  of 
water  and  five  ounces  of  sweet  cow's  milk.  Warm  slowly  and  stir 
until  thick.  Eemove  from  fire,  stirring  for  five  minutes,  replace 
over  fire,  and  remove  when  quite  thick.  As  the  diastase  continues 
to  act  the  mass  will  become  thin  and  sweet.  Boil  and  strain.  It 
contains  gluten  and  albumin  of  flour  and  barley,  besides  dextrin  and 
maltose.  The  food  thus  prepared  is  highly  nutritious,  for  it  not  only 
contains  the  proteids  of  milk,  but  those  also  of  wheat  flour  and 
malted  barley  (gluten  and  albumin),  as  well  as  the  predigested 
starch.  The  malted  foods  which  are  made  with  desiccated  milk 
and  malted  flour  are  deficient  in  fats,  salts  and  protein,  but  the 
lack  of  these  substances  may  be  supplied  by  the  addition  to  the 
food,  when  used,  of  cream  and  beef  juice.  The  digestibility  of  bread 


176         FOODS  AND  FOOD  PREPARATIONS 

may  be  increased  by  adding  5  grains  of  diastase  to  the  pound  of 
flour  mixed  in  the  dough. 

For  manufacturing  malted  foods  the  wheat  or  barley  flour  should 
be  baked  in  order  to  rupture  the  starch  granules  and  make  them 
more  soluble. 

Examples  of  Liebig's  type  of  dextrinized  foods  are  :  Mellin's  Food, 
Horlick's  Food,  Savory  &  Moore's  Infant  Food. 

According  to  Leed's  analysis,  the  best  samples  of  Mellin's  and 
Horlick's  foods  contain  no  starch,  but  a  large  percentage  (Mellin's 
68.18  per  cent,  Horlick's  76.83)  of  soluble  carbohydrates,  and  about 
10  per  cent  each  of  albuminoids  —  if  the  process  is  complete.  Savory 
&  Moore's  food  he  finds  contains  considerable  starch. 

Mellin's  Food  consists  of  brown  sweetish  granules,  easily  soluble 
in  both  hot  and  cold  water,  milk,  etc.  It  is  made  of  coarsely  ground 
wheaten  flour  with  the  addition  of  malt  and  potash.  It  is  then 
digested  with  water  at  a  moderate  temperature  to  form  dextrin  and 
sugar.  Afterwards  it  is  strained  through  sieves  and  evaporated  in  a 
vacuum  pan. 

Mellin's  Food  is  often  fed  to  infants,  but  it  contains  too  much 
sugar  without  fat  for  a  wholesome  baby's  food  for  continued  use  in 
quantity.  It  may  be  resorted  to  temporarily  when  good  cow's  milk 
cannot  be  obtained.  The  food  may  be  prepared  for  use  as  follows  : 

For  an  Infant  One  Month    Old. 

Mellin's   Food    ..........................      5  level  teaspoonfuls. 

Fresh    milk    ............................    10  tablespoonfuls. 

Hot   water    .............................    22  " 

For  an  Infant  of  Three  Months  and  for  Delicate    Children. 

Mellin's   Food    ...      8  level  teaspoonfuls    (equal  to  1  heaping  tablespoonf  ul  )  . 
Fresh  milk   ......    16  tablespoonfuls    (equal  to  %  pint). 

Hot   water    ......    16  tablespoonfuls   (equal  to 


For  Infants  of  Sim  Months  and    Over. 

Mellin's  Food    ......................      2  heaping   tablespoonfuls. 

Fresh   milk    ........................    24  tablespoonfuls    (equal  to  %  pint)  . 

Hot  water    .........................      8  tablespoonfuls    (equal  to  %  pint)  . 

Mix  the  Mellin's  Food  with  a  little  hot  water  into  a  smooth  paste,  add  the 
remainder  of  the  water  and  the  milk,  and  mix  thoroughly.  Keep  this  mixture 
on  the  ice  or  in  a  cool  place. 

Bcngcr's  Food  is  a  preparation  of  wheaten  flour  to  which,  after 
cooking,  pancreatic  extract  is  added.  When  mixed  with  warm  milk 
both  milk  and  flour  are  newly  digested.  A  tablespoonful  of  the  food 
is  dissolved  in  two  ounces  of  cold  milk.  Then  half  a  pint  of  boiling 
milk  or  milk  and  water  is  slowly  stirred  in.  Further  pancreatiniza- 


VEGETABLE  FOODS 

tion  is  then  arrested  by  boiling  for  twenty  to  thirty  minutes.  The 
preparation  has  no  bad  taste  and  is  a  nutritious  and  digestible  food 
in  cases  of  gastric  ulcer,  phthisis,  dyspepsia,  etc. 

3.  Foods  Which  are  Dextrinized  and  Then  Evaporated  with  Milk  or 
Cream. —  These  are  sometimes  called  "  milk  foods."  Such  are  Lac- 
tated  Food,  Malted  Milk,  Loeflund's  Cream  Emulsion,  Nestle's 
Food,  Gerber's  Food. 

The  general  process  by  which  foods  of  this  class  are  made  is  as 
follows : 

Wheaten  or  other  flour  is  first  made  into  dough,  baked,  ground, 
mixed  with  more  or  less  condensed  milk  or  cream,  and  then  dried  at 
a  moderate  temperature.  By  addition  of  malt  or  diastase  the  starch 
is  partially  converted  into  dextrin  and  maltose,  and  the  albuminoids 
are  rendered  slightly  more  soluble,  the  casein  is  dried,  and  the  lact- 
albumin  is  precipitated. 

One  form  of  "  cereal  milk  "  is  made  from  a  mixture  of  wheat  and 
barley  meal  with  milk. 

It  is  claimed  for  some  of  the  malted  foods  prepared  for  infant 
and  invalid  use  that  the  artificial  digestion  is  not  wholly  completed, 
and  this  is  said  to  be  an  advantage  in  stimulating  the  digestive  organs. 

Malted  milk  is  a  powdered  sterilized  preparation  of  pure  cow's 
milk  and  extracts  of  malted  barley  and  wheat,  the  starch  of  which 
has  been  converted  into  dextrin.  The  mixture  is  dried  in  vacuo. 

The  casein  of  the  milk  is  predigested  by  a  vegetable  ferment. 
The  preparation  keeps  well  while  hermetically  sealed,  and  when  re- 
quired for  use  for  an  infant,  fron  one  to  four  teaspoonfuls  are  dis- 
solved in  from  eight  tablespoonfuls  to  a  half  pint  of  water.  For 
adults,  two  tablespoonfuls  of  the  powder  in  a  half  pint  of  water  make 
the  strength  of  cow's  milk.  The  idea  of  this  preparation  is  to  furnish 
a  substitute  for  human  milk  which  will  keep  well,  be  always  ready 
for  use,  and  in  which  dextrin  takes  the  place  of  additional  fat. 

It  resembles  Mellin's  Food,  except  that  it  contains  some,  though 
not  enough,  fat.  It  is  used  in  about  the  same  proportion.  It  makes 
a  better  invalid  food  for  adults  than  for  infants,  and  patients  with 
enteric  fever  and  severe  gastrointestinal  disorder  take  it  with  benefit. 

NestU's  Food  is  prepared  in  Switzerland,  at  Vevay,  from  pasteur- 
ized cow's  milk,  which  is  condensed  and  to  which  ground  wheaten 
bread  crust  is  added  after  dextrinization.  Cane  sugar  is  mixed  in, 
and  the  mass  is  dried,  pulverized,  and  hermetically  sealed  in  tins. 
For  use  it  requires  dilution  with  water.  It  contains  25  per  cent  of 
sugar,  27.36  of  maltose  and  dextrin,  5.50  of  fat,  15.39  of  starch, 
6.57  of  lactose  and  14.34  of  proteids,  besides  salts  and  water. 


178         FOODS  AND  FOOD  PREPARATIONS 

Carnrick's  Food  is  composed  of  evaporated  or  desiccated  milk 
partly  peptonized  and  thoroughly  sterilized  by  heat,  45  parts;  dextrin 
and  soluble  starch,  45  parts :  milk  sugar,  10  parts. 

Eskay's  albuminized  food  consists  of  the  prepared  cereals  —  oats, 
barley,  maize,  and  wheat  together  with  lactose  and  egg  albumin.  It 
contains  11.33  per  cent  of  total  solids. 

Bread  Jelly. —  A  bread  jelly  may  be  made  to  add  to  milk  for  in- 
valids and  for  use  while  weaning  infants  who  are  old  enough  to  digest 
a  little  starch  —  i.  e.,  over  one  year  of  age.  The  crumb  of  stale  bread 
is  broken  into  small  fragments  and  covered  with  boiling  water,  in 
which  it  is  allowed  to  soak  until  well  macerated.  The  water  is  then 
strained  off,  fresh  water  is  added,  and  the  mass  is  boiled  until  quite 
soft.  On  cooling,  a  jelly  forms  which  may  be  mixed  with  milk  in 
any  desired  proportion. 

Farina  is  a  general  name  meaning  flour.  As  sold  by  grocers  in  this 
country,  it  is  usually  made  from  wheat,  but  much  of  the  gluten  and 
bran  has  been  separated,  rendering  it  less  nutritious  than  whole  wheat. 
In  cases  of  diarrhoea  it  is  more  bland  and  less  irritant  than  whole 
wheat.  The  name  "  farina "  is  also  applied  to  fine  white  potato 
starch,  which  forms  a  jelly  when  cooke'd,  like  arrowroot. 

Wheatena  is  a  nutritious  food  containing  all  the  wheat  berry  ex- 
cepting the  husk,  and  thereby  differing  from  finer  preparations  in 
which  the  layer  of  gluten  cells  is  removed  with  the  bran.  The  starch 
granules,  moreover,  have  been  ruptured  by  heat.  It  is  commonly 
eaten  as  a  thin  mush  or  porridge. 

Cracked  or  rolled  wheat  has  similar  advantages. 

Shredded  wheat,  trisket  and  pulled  bread  are  modified  breadstuffs 
which  lately  have  become  deservedly  popular  among  dyspeptics  on  ac- 
count of  their  easy  digestibility. 

Shredded  wheat  biscuit  is  made  of  wheat  which  is  thoroughly 
cleaned,  washed,  cooked,  and  treated  by  machinery  which  draws  out 
the  wheat  kernels  into  long,  continuous  filaments,  thus  breaking 
down  their  structure  without  separation  of  the  component  parts. 
Eighty  such  filaments  are  obtained  within  a  space  four  inches  wide; 
they  are  porous  and,  unlike  dough,  are  capable  of  absorbing  the  diges- 
tive fluids,  thus  no  leavening  or  baking  powder  is  required.  The 
shreds  are  folded  by  mashing  into  oblong  biscuits,  which  are  recooked 
at  successive  temperatures  until  all  moisture  is  driven  off  and  they 
are  ready  for  use.  They  may  be  eaten  soaked  in  milk,  cream,  or 
broth,  or  moistened  with  hot  water  and  buttered. 

Crackers. —  All  kinds  of  crackers  enter  more  into  the  dietary  in 
America  and  England  (where  they  are  called  "biscuits")  than  in 


VEGETABLE  FOODS 


179 


any  other  country.  The  lighter  forms  of  wafers  and  rusk  are  nutri- 
tious and  very  easily  digested  by  invalids  having  mild  gastric  dis- 
order, for  the  starch  has  been  well  torrefied. 

Crackers  vary  much  in  hardness  and  flavor,  but,  generally  speak- 
ing, they  are  quite  as  digestible  as  good  bread.  The  simplest  forms, 
such  as  water  crackers  or  milk  crackers,  are  made  with  flour  and 
water  or  milk,  to  which  a  little  salt  is  added,  after  which  they  are 
baked  in  flat  shapes  so  as  to  become  hard  and  more  or  less  brittle. 
Soda  is  sometimes  added.  If  it  is  desirable  to  have  them  less  friable, 
butter  may  be  added  in  small  quantity.  The  hard  unleavened  prepa- 
rations known  as  "  ship  biscuits,"  "  hard-tack,"  and  "  pilot  biscuits," 
which  form  an  important  article  of  diet  for  sailors  at  sea,  are  manu- 
factured upon  these  principles. 

Ship  biscuits  are  so  dry  and  firm  that  they  are  much  less  bulky 
than  bread,  and  it  is  estimated  that  three-fourths  of  a  pound  of  such 
biscuits  is  equivalent  to  one  pound  of  bread  in  actual  nutritive  value. 

Most  biscuits,  if  kept  long  exposed  to  the  air,  become  exceedingly 
dry  and  tasteless,  although  they  do  not  readily  mold.  The  biscuits 
known  as  "  hard-tack  "  are  usually  made  five  inches  square  and  are 
perforated  with  small  holes.  They  have  the  advantage  of  keeping 
well  for  a  very  long  time  and  remaining  edible,  although  they  are  not 
very  palatable  even  when  fresh.  They  are  extremely  tough,  and  re- 
quire soaking  in  milk  or  water  before  they  can  be  eaten. 

Granose  is  a  flaky  form  of  entire  wheat  biscuit  prepared  by  the 
Battle  Creek  (Mich.)  Sanitarium  Health  Food  Company.  It  may  be 
eaten  with  cream  or  hot  milk,  and  is  palatable  and  nutritious.  Gran- 
ola  is  a  similar  preparation. 

Composition  of  Crackers    ( Clark ) . 


Water. 

Nutrients. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Mineral 
waters. 

Boston  crackers    

Percent. 
8.2 

Percent. 
91.8 

Percent. 

10.7 

Percent. 

9  9 

Percent. 

68.8 

Percent. 

2.4 

Soda  crackers   

8.0 

92.0 

10.3 

9.4 

70.5 

1.8 

Pilot  crackers   

7.9 

92.1 

12.4 

4  4 

74.2 

1.1 

Graham  crackers    

5.0 

95.0 

9.8 

13  5 

69.7 

20 

Oatmeal  crackers   

4.9 

95.1 

10.4 

13  7 

696 

1  4 

Oyster  crackers     

3.8 

96.2 

11  3 

4  8 

77.5 

26 

Semolino  is  a  name  having  two  applications.  In  France  it  de- 
notes the  hard  central  substance  of  the  wheat  grains  which  are  re- 
tained in  the  bolting  machine  after  separation  of  the  finer  portion 
which  has  passed  through:  but  in  Italy  the  word  is  used  to  denote 
the  finer  portion  itself,  consisting  of  fine  hard  granules  rounded  by 


180          FOODS  AND  FOOD  PREPARATIONS 

grinding.  The  larger  sizes  contain  much  gluten,  and  may  be  used  to 
thicken  soups.  The  granules  swell  in  water.  When  the  grinding  and 
sifting  process  is  carried  further  the  starch  granules  are  obtained  in 
the  fine  powder  which  constitutes  flour. 

Semolino  is  used  extensively  in  the  manufacture  of  what  are  called 
"  alimentary  pastes/'  such  as  macaroni. 

Macaroni  is  made  by  mixing  semolino  made  from  hard  flinty  wheat 
into  a  paste  which  is  kneaded  and  put  into  a  cylinder,  the  bottom  of 
which  is  pierced  with  holes.  A  piston  descends  in  the  cylinder,  and 
the  paste  issues  from  the  perforations  in  the  form  of  long  thin  tubes, 
which  are  cooled  by  a  current  of  air,  cut  in  lengths,  and  dried  on 
screens.  As  much  as  twenty  million  pounds  of  macaroni  are  manu- 
factured annually  in  Lyons  alone.  It  contains  16  to  18  per  cent  of 
gluten,  whereas  bread  holds  10  to  11  per  cent. 

Sir  Henry  Thompson  says,  in  speaking  of  macaroni,  that,  "  weight 
for  weight,  it  may  be  regarded  as  not  less  valuable  for  flesh-making 
purposes  in  the  animal  economy  than  beef  or  mutton.  Most  people 
can  digest  it  more  easily  and  rapidly  than  meat." 

After  thorough  soaking  and  when  well  cooked  by  boiling  or  stew- 
ing in  milk  or  stock  it  is  very  nutritious,  and  'it  is  often  agreeably 
combined  with  cheese,  although  this  is  not  advised  for  persons  with 
feeble  digestive  power. 

The  use  of  Italian  pastes,  such  as  spaghetti  and  vermicelli,  in  this 
country  is  extensive,  but  by  no  means  as  much  so  as  their  intrinsic 
value  deserves.  They  are  manufactured  from  flour  from  which  the 
starch  has  been  in  part  removed,  and  hence  contain  a  relatively  large 
proportion  of  protein.  Although  very  wholesome  they  are  tough, 
and  require  prolonged  cooking.  The  vermicelli  which  is  sold  in  the 
form  of  letters,  to  use  in  soups,  cannot  be  boiled  sufficiently  to  be 
thoroughly  digestible  unless  the  letters  lose  their  shape. 

Buckwheat. —  Buckwheat,  or  "  blackwheat. "  as  it  sometimes  is 
called,  is  indigenous  to  temperate  climates,  and  in  some  parts  of  the 
world,  notably  in  Eussia,  Siberia,  and  Brittany,  it  constitutes  a  staple 
of  diet,  but  in  the  United  States  it  is  the  least  important  of  the  cere- 
als, and  is  used  rather  as  a  luxury  for  making  griddle  cakes.  The 
buckwheat  produced  in  the  United  States  is  raised  mainly  in  Xew 
York,  Pennsylvania,  and  some  of  the  New  England  States.  Buck- 
wheat bread  is  nutritions,  but  it  crumbles  and  does  not  keep  well. 
Buckwheat  farina  and  groats  are  made.  Buckwheat  flour  has  less 
protein  and  more  carbohydrate  than  wheat  flour.  According  to  T. 
F.  Hunt  it  contains,  water  12.6  per  cent,  protein  10,  fat  2.2,  carbohy- 
drate 64. 5.  crude  fiber  8.7  and  ash  2  per  cent. 


VEGETABLE   FOODS  181 

Soya  bread  is  made  from  an  oily  pea  which  grows  in  China  and 
Japan,  and  is  used  sometimes  by  diabetics,  for  it  contains  over  one- 
third  part  of  gluten  and  but  1.17  per  cent  of  glucose.  (See  Diabetes). 

Millet  and  sorghum  are  grown  in  the  warmest  parts  of  Asia  and 
Africa,  and  to  some  extent  in  southern  Europe.  In  Eussia  millet  is 
sold  as  a  white  meal.  White  sorghum,  which  is  a  grass  or  cane,  is 
converted  into  flour  called  doura,  and  in  Africa,  mingled  with  barley, 
it  is  distilled  into  beer.  A  fine  quality  of  alcohol  may  be  made  from 
it.  In  the  United  States  it  is  grown  chiefly  for  molasses  and  sirup; 
sugar  is  also  made  from  it.  Bread  made  from  either  millet  or  sor- 
ghum meal  is  fairly  palatable  and  nutritious  when  warm,  but  when 
it  becomes  cold  it  grows  dark  and  crumbles.  The  grains  are  hulled 
like  barley  and  are  ground  into  flour,  which  is  either  eaten  pure  or 
mixed  with  bread.  Millet  is  a  grass  raised  largely  in  India,  China, 
Egypt,  along  the  west  coast  of  Africa,  in  Italy,  Spain,  and  Portugal. 
There  are  many  sub-varieties.  It  contains,  on  an  average,  over  7 
per  cent  of  fat,  nearly  10  per  cent  each  of  proteid  and  dextrin,  60 
per  cent  of  starch,  and  2  of  sugar  (Parkes). 

Eye. —  Eye  rriay  be  said  to  stand  very  close  to  wheat  in  impor- 
tance as  a  food.  In  Europe  it  is  more  in  use  for  bread-making  than 
in  this  country,  where  it  is  eaten  mainly  by  the  Germans.  In  Ger- 
many the  rye  production  is  double  that  of  wheat,  and  in  Eussia  it 
is  three  times  greater.  Former  generations  lived  almost  entirely 
upon  rye  in  France,  as  they  did  upon  oats  in  Scotland  and  parts  of 
England,  wheat  being  an  almost  unobtainable  luxury. 

Eye  yields  a  coarser,  darker,  less  well-raised  bread  than  wheat,  but 
is  about  equally  nutritious,  although  not  always  so  digestible,  and  it 
is  somewhat  laxative.  In  general,  the  statements  made  in  the  pre- 
ceding pages  (pp.  161,  164)  in  regard  to  bread-making,  etc.,  with 
wheaten  flour,  may  be  applied  to  rye  flour. 

Eye  bread  contains  a  less  elastic  gluten  than  wheaten  bread,  and  it 
takes  less  time  to  raise  and  bake  it,  provided  the  oven  is  very  hot. 
If  properly  made  it  is  easily  assimilated,  and  many  like  its  flavor. 

Eye  is  often  combined  with  wheat  in  France,  under  the  name  of 
meteil,  and  in  Spain  and  Greece  a  mixture  of  the  same  name  is  made 
with  barley  instead  of  wheat. 

Corn. —  Maize,  or  Indian  corn,  is  grown  very  extensively  in  tem- 
perate and  warm  climates  all  over  the  world.  It  may  be  dried, 
parched,  and  roasted  whole,  or  ground  into  meal  of  various  degrees 
of  fineness. 

There  are  some  300  varieties  of  corn,  but  the  common  kinds  are 
known  simply  as  white,  yellow,  and  red. 


182 


FOODS  AND  FOOD  PREPAEATION8 


a 


The  chief  preparations  of  corn  are  hominy,  samp,  cornmeal, 
cracked  corn,  cerealine,  and  maizena  (a  South  American  cornmeal, 
used  in  the  manufacture  of  a  drink  called  "  chicca"). 

Aside  from  its  use  as  a  food,  corn  furnishes  alcohol  and  liquor, 
as  well  as  glucose  and  laundry  starch. 

Chittenden  and  Osborn  have  made  an  elaborate  research  into  the 
chemical  composition  of  the  "proteids  of  the  corn  or  maize  kernel." 
These  consist  of  "three  globulins,  one  or  more  albumins,  and  an 
alcohol-soluble  proteid"  called  maize  fibrin  or  zein. 

Corn  is  a  wholesome  cereal,  for  it  contains  considerable  fat  (Fig. 

32)  and  proteid  (Fig.  33)  as  well 
as  starch,  and  it  furnishes  abun- 
dant energy,  producing  heat.  It 
is  very  fattening  for  both  the 
lower  animals  and  man.  In  the 
Southern  States  and  in  France  it 
is  fed  largely  to  horses. 

As  a  fresh  vegetable,  corn  is 
less  used  in  Europe  than  in 
America,  perhaps  on  account  of 
the  prevalent  idea  that  it  is  a 
hog's  food,  although  cornmeal  is 
employed  for  baking  into  cakes 
and  to  mix  with  flour  in  bread- 
making.  Eaten  as  a  vegetable, 
unless  very  young  and  tender, 
corn  is  one  of  the  least  digestible 
foods,  and  canned  corn  is  notor- 
iously so.  This  is  chiefly  on  ac- 
count of  the  toughness  of  the 
husk  of  the  kernel,  which  often 
is  found  in  the  feces  practically  unaltered  by  its  transit  through  the 
body.  Hence  it  may  cause  flatulency,  indigestion,  and  diarrhoea. 

Cornmeal,  on  the  other  hand,  is  quite  digestible,  and,  like  oatmeal, 
is  somewhat  laxative.     As  compared  with  wheaten  flour,  it  contains 
more  fat,  having  about  9  per  cent,  but  it  is  deficient  in  salts.     It 
makes  a  dry,  friable  bread,  for  corn  contains  no  elastic  gluten. 
Samp  is  a  very  digestible  coarse  form  of  corn  when  well  boiled. 
When  maize  becomes  moldy  it  causes  the  disease  known  as  pellagra. 
(See  Diet  in  Pellagra.) 

Polenta  is  a  maize  meal  extensively  used  in  Italy. 
Cornstarch  is  very  white  and  soft.     It  contains  53  per  cent  of 


FIG.  31. — SECTION  OF  GRAIN  OF  CORN. 

a,  Skin  and  Testa;  6,  Membrane; 
c.  Embryo;  d,  Endosperm;  f, 
Scuttelum.  (U.  S.  Dept.  of  Agn., 
Farmers'  Bui.,  No.  112,  Helen  W. 
Atwater.) 


VEGETABLE  FOODS 


183 


FIG.  32. —  KERNELS  OF  CORN:     HIGH-OIL  (ON  THE 

LEFT)   AND  Low-OiL   (ON  THE  EIGHT). 
(U.  S.  Dept.  of  Agri.,  Farmers'  Bui.,  No.  193.) 


starch.     The  best  grades  are  used  as  a  substitute  for  arrowroot.,  and 
make  a  -wholesome  invalid  food,  being  very  white  and  soft. 
Indian  meal  is  yellow,  granular,  and  coarser  than  cornstarch. 
Mush    is    made    of 
well-ground   cornmeal 
or  Indian  meal.     The 
cereal     is     boiled     in 
salted    water,     and 
when    cooked    is    not 
pasty,  but  mixes  well 
with    cream,    and    is 
very     digestible     and 
nutritious. 

Corn-syrup  has 
been  especially  recom- 
mended as  a  nutri- 
tious food  for  the  tu- 
berculous. 

Rice. —  Although  less  eaten  in  this  country  than  wheat,  corn,  and 
rye,  except  in  the  Southern  States,  rice  constitutes  the  staple  food 
of  a  majority  of  the  world's  inhabitants.  Asia  produces  most  of  the 
rice  consumed,  but  a  little  is  grown  in  Spain,  Italy,  and  Portugal. 
According  to  Clark,  "  in  Asia  a  large  part  of  the  population  con- 
sume 275  pounds  per  head 
a  year,"  and  nearly  two  bil- 
lion pounds  are  used  per 
year  in  Europe.  In  the 
United  States,  where  rice 
was  first  introduced  in 
1694,  it  is  chiefly  grown  in 
South  Carolina.  There  are 
several  hundred  varieties  of 
rice,  the  two  principal 
classes  being  the  dry  or 
mountain  rice,  and  the  wet 
rice,  which  grows  in  flat 
marsh-land,  periodically  in- 
undated. Both  the  Chinese 
and  Japanese  make  a  wine  from  rice3  and  a  vinegar  also  may  be 
obtained. 

The  native  Oriental  method  of  treating  rice  is  to  beat  the  kernels 
of  grain  out  of  their  husks  in  wooden  mortars,  and  for   European 


FIG.  33. —  KERNELS  OF  CORN:  HIGH-PRO- 
TEIN (ON  THE  LEFT)  AND  LOW-PROTEIN 
(ON  THE  RIGHT). 

(U.  S.  Dept.  of  Agri.,  Farmers'  Bui.,  No. 
193.) 


184  FOODS  AND  FOOD   PREPARATIONS 

markets  they  are  glazed  by  shaking  in  a  sheepskin-lined  drum.  They 
are  also  bleached,  and  may  be  broken  after  decortication  and  ground 
into  a  flour. 

"  Puffed  rice  "  is  a  new  preparation  by  which  the  rice  kernels  are 
expanded  in  a  vacuum,  heated  and  browned,  so  that  they  may  be  eaten 
with  sugar  and  cream,  without  cooking.  This  form  of  rice  has  some- 
what the  flavor  of  pop-corn  and  is  easily  digested,  of  agreeable  taste, 
and  very  nutritious.  "  Puffed  wheat  "  is  similarly  made. 

Bice  contains  more  starch  than  any  other  cereal  —  from  75  to  85 
per  cent  —  and  is  exceedingly  digestible  for  invalids  when  properly 
cooked,  so  that  the  individual  grains  are  swollen  or  softened.  This 
object  is  best  attained  by  the  process  of  steaming.  The  digestibility 
of  plain  boiled  rice  is  improved  by  eating  it  with  a  little  fresh  butter, 
which  coats  the  kernels  and  prevents  their  agglutination  into  a  pasty 
mass.  If  the  rice  is  insipid  it  may  be  spiced  or  flavored  with 
raisins.  Bice  pudding,  milk  and  rice,  and  rice  with  beefsteak  juice 
constitute  excellent  foods  for  young,  growing  children,  and  for  use  in 
convalescence  from  typhoid  fever,  diarrhoeas,  and  many  other  dis- 
eases. It  is  also  advantageous  to  eat  rice  with  fruit,  such  as  apples 
or  prunes. 

Eice  should  not  be  depended  upon  without  some  form  of  animal 
food,  for  it  contains  too  little  nitrogen  to  satisfy  the  needs  of  the 
system. 

Bread  cannot  be  made  economically  from  rice,  on  account  of  the 
small  amount  of  protein  which  this  cereal  contains,  and  the  conse- 
quent lack  of  stability  in  the  shape  of  the  loaf,  and  unless  wheat  be 
added  in  large  proportions,  such  bread  is  indigestible  and  watery. 

Barley. —  Barley  ranks  very  close  to  wheat  in  nutritive  power,  and 
cooked  barley  meal,  like  wheaten  flour,  contains  gum,  albuminoids, 
starch,  and  dextrin.  As  compared  with  wheat,  barley  contains  more 
fat,  salts,  and  indigestible  cellulose,  less  protein,  and  less  digestible 
carbohydrate.  The  proportion  of  bran  to  the  grain  is  21  to  79. 

The  employment  of  barley  bread  for  food  is  of  very  ancient  date, 
reaching  back  to  the  early  days  of  the  Greeks  and  Hebrews,  but  with 
the  spread  of  the  use  of  potatoes  and  the  cheapening  of  wheaten  flour, 
it  has  fallen  into  comparative  disuse,  and  in  the  United  States  barley 
is  mainly  used  to  thicken  soups  and  in  the  manufacture  of  beer.  In 
some  of  the  Pacific  States  it  is  fed  to  horses.  Pearl  barley  is  made 
by  depriving  barley  corns  of  their  outer  shells  or  covering,  and  then 
subjecting  them  to  nibbing  between  a  single  millstone  and  a  sheet  of 
rasped  iron  or  wire  cloth,  a  process  which  polishes  the  kernels  and 
rounds  them  off. 


VEGETABLE   FOODS  185 

Barley  water  makes  an  excellent  diluent  of  milk  and  a  demulcent 
drink  for  infants  and  invalids.  For  the  latter  it  may  be  flavored 
with  lemon  juice.  It  may  be  made  as  follows :  Grind  half  an  ounce 
of  pearl  barley  in  a  coffee  mill,  add  six  ounces  of  water,  boil  twenty 
minutes,  add  salt,  and  strain.  It  should  be  made  fresh  daily  and 
kept  in  a  cool  place.  It  is  better  than  oatmeal  water  whenever  the 
bowels  are  loose.  The  latter,  made  in  a  similar  manner,  is  to  be  pre- 
ferred when  constipation  exists.  The  viscidity  of  barley  water  is  due 
to  its  proteids. 

Oatmeal. —  Oats  contain  considerable  fat,  protein,  salts,  and  indi- 
gestible cellulose,  in  addition  to  a  large  percentage  of  starch.  They 
have  been  eaten  in  Germany  for  over  a  thousand  years,  and  consti- 
tuted the  original  grain  food  for  all  Europe. 

Oatmeal  is  much  less  used  than  other  cereals  for  bread  because 
it  lacks  gluten,  although  it  is  still  so  employed  to  a  limited  extent 
among  the  poorer  classes  in  France.  It  makes  a  dark,  bitter  bread, 
but  forms  a  better  porridge  than  can  be  obtained  from  either  rice  or 
barley. 

The  use  of  oatmeal  porridge  by  all  classes  is  very  extensive  through- 
out the  United  States.  This  is  largely  attributable  to  improved 
methods  of  its  preparation  by  high  milling,  rolling,  etc.  Scotch 
groats  are  prepared  by  removing  the  outer  husk,  leaving  the  grain 
almost  whole.  The  grain  is  then  reground  between  closer  set  mill- 
stones. It  forms  two  grades  of  meal,  the  coarser  of  which  is  used  for 
porridge  and  the  finer  to  make  bannocks  or  oatmeal  cakes.  A  good 
deal  of  the  oatmeal  sold  in  America  is  identical  with  Scotch  groats. 
True  Scotch  groats  are  heated  by  the  miller  over  perforated  iron 
plates  and  slightly  parched  for  three  or  four  hours  before  being 
ground.  For  those  who  can  digest  oatmeal  well,  it  ranks  among  the 
cheapest  and  most  satisfying  of  foods. 

The  nutritious  value  of  oatmeal  is  great,  but  it  depends  very  largely 
upon  the  skill  with  which  it  is  cooked.  It  is  not  infrequently  cooked 
in  such  a  manner  that  the  individual  grains  are  left  whole,  but  in 
this  form  the  flavor  is  less  well  developed  than  it  is  by  prolonged 
cooking;  the  oatmeal  granules  are  much  more  difficult  of  digestion, 
and  are  capable  of  exciting  gastrointestinal  irritation  in  feeble  per- 
sons. But  for  many  persons  oatmeal  thus  cooked  possesses  a  de- 
cided advantage  from  the  fact  that  it  is  less  completely  absorbed, 
leaving  a  considerable  residue  which  adds  to  the  bulk  of  fecal  matter, 
excites  peristaltic  action,  and  reduces  the  liability  to  constipation. 
For  most  persons,  however,  and  especially  for  all  those  with  limited 
digestive  power,  oatmeal  should  be  cooked  so  thoroughly  as  to  acquire 


186          FOODS  AND  FOOD  PREPARATIONS 

the  consistence  which  enables  it  to  be  poured  easily,  and  on  cooling 
it  should  form  a  tender,  gelatinous  mass. 

Oatmeal  is  a  very  hearty  food,  and  those  who  eat  much  of  it  should 
live  a  vigorous  outdoor  life.  If  ill-cooked  and  if  given  to  very  young 
children,  it  occasions,  colic,  flatulence,  and  rashes. 

It  is  best  when  of  recent  crop  and  freshly  ground.  If  it  is  kept 
long  it  absorbs  moisture,  and,  losing  its  delicate  flavor,  becomes  moldy 
and  sour. 

The  following  analysis  of  oatmeal  is  given  by  Letheby: 

Nitrogenous  matter   12.6  per  cent. 

Carbohydrates,   starch,   etc    63.8 

Fatty  matter 5.6 

Mineral   matter    3.0 

Water 15.0 


Total     100.0 

The  proportion  of  bran  to  the  grain  is  44  to  66. 

Oatmeal,  like  cornmeal,  has  more  protein  and  fat  than  the  flours 
and  meals  derived  from  other  cereals,  and  hence,  like  bread,  it  may 
be  eaten  daily  without  impairing  the  appetite. 

Revalenta  Arabica  is  a  farinaceous  food  much  eaten  in  some  parts 
of  Europe,  which  is  a  mixture  of  several  meals,  principally  ground 
peas,  beans,  corn,  and  lentils,  but  barley  and  oatmeal  may  be  in- 
cluded. 

Arrowroot. —  Arrowroot  is  derived  from  the  rhizomata  or  root 
stocks  of  several  kinds  of  tropical  plants  grown  in  both  the  East  and 
West  Indies.  The  roots  are  washed,  reduced  to  a  pulp,  strained, 
dried,  and  pulverized  into  a  very  fine  starchy  flour.  The  best  flour 
is  made  from  the  Maranta  arundinacea.  It  is  obtainable  in  market  in 
the  form  of  a  fine  white  powder,  and  consists  of  exceptionally  pure 
starch,  the  granules  of  which  are  small  and  friable.  It  has  a  very 
bland,  insipid  taste,  and  it  is  as  digestible  or  more  so  when  cooked 
than  any  other  starch  which  is  used  in  making  gruel  or  jellies  for 
invalids.  In  the  form  of  a  jelly  it  keeps  longer  without  souring  than 
do  many  other  forms  of  starchy  food,  such  as  the  potato;  and  in  se- 
vere cases  of  dyspepsia,  when  much  gastric  irritation  exists,  it  often 
constitutes  a  serviceable  article  of  diet.  Arrowroot  is  fed  sometimes 
to  young  infants,  but  it  is  unwholesome  for  them,  and  ferments  in  the 
stomach. 

Tous-les-mois. —  Tous-les-mois  is  a  starch  derived  from  a  West 
Indian  tuber  by  maceration,  straining,  washing,  and  drying.  It  is 
used  for  the  same  purpose  as  arrowroot.  Its  granules  are  the  largest 


VEGETABLE  FOODS  187 

of  any  of  the  food  starches,  but  they  are  quite  digestible  and  nutritious 
for  invalids. 

Salep. —  Salep  is  a  starchy  food  which  is  obtained  from  the  tuber- 
cles of  certain  Oriental  orchids.  It  is  a  mixture  of  starch  and  mu- 
cilage which  makes  a  useful  demulcent  drink. 

Tapioca,  Cassava. —  Tapioca  and  cassava  are  made  from  the  rhizo- 
mata  of  the  Manioc  utilissima  or  Manihot,  a  common  plant  in  tem- 
perate and  tropical  regions.  It  is  extensively  grown  in  South  and 
Central  America,  Africa,  and  the  West  Indies.  Manioc  flour  forms 
the  basis  of  food  of  the  natives,  and  when  made  into  bread  and  cakes 
it  replaces  the  wheaten  bread  of  Europe  and  North  America.  Cas- 
sava contains  a  poisonous  juice  that  first  must  be  drained  off. 

Tapioca,  which  is  purified  cassava,  is  made,  like  sago,  by  drying 
on  hot  plates,  the  clarified  starch  being  heated  first  into  a  paste  in 
large  metal  pans.  It  is  an  almost  pure  starch.  The  granules  are 
not  tough,  and  are  very  easily  digested,  so  that  they  form  one  of 
the  most  useful  of  the  amylaceous  foods  for  persons  with  feeble 
digestion.  Tapioca  may  be  eaten  alone  in  the  form  of  puddings  with, 
cream  or  flavored  with  lemon  juice,  wine,  nutmeg,  or  other  spice  or 
aromatic,  or  may  be  used  to  thicken  broths  or  soups.  "  Pearl  tapi- 
oca "  is  a  spurious  article  made  from  potato  starch. 

Air-dry  tapioca  contains  11.97  per  cent  of  water.  Water-free 
tapioca  consists  of:  protein  0.79,  carbohydrates  98.90,  and  ash  0.31 
(C.  D.  Woods  and  L.  H.  Merrill). 

Sago. —  Sago  is  an  easily  digestible  form  of  starch  derived  from 
the  pith  found  in  the  stem  of  different  varieties  of  palm  from 
Sumatra,  Java,  and  Borneo.  It  is  commonly  sold  in  market  in  a 
granular  form,  and  is  known  as  "pearl  sago."  This  is  prepared  by 
adding  water  to  sago  flour  so  as  to  form  a  paste  which  is  run  through 
sieves  to  granulate  it.  The  spherical  form  of  the  granules  is  ac- 
quired by  allowing  them  to  fall  into  a  shallow  iron  pan  held  over  a 
fire.  Sago  is  made  with  milk,  cream,  and  eggs  into  nutritious  pud- 
dings, and  it  may  be  used  to  thicken  broths  and  soups  of  various 
kinds.  It  has  an  agreeable  flavor,  somewhat  more  delicate  than 
tapioca,  which  it  resembles,  and  is  an  invaluable  adjunct  to  the  invalid 
dietary. 

Iceland  moss  (Cetraria  Islandica)  is  a  lichen  sometimes  employed 
as  food  after  purifying  it  by  washing.  It  contains  at  first  various 
bitter  principles,  which  must  be  eliminated.  It  can  be  made  into 
bread  or  used  as  an  ingredient  of  blancmange,  etc.  It  has  been, 
recommended  by  Senator  and  others  for  use  by  diabetics  to  replace 
ordinary  bread,  and  it  makes  a  convenient  vehicle  for  the  adminis- 


188          FOODS  AND  FOOD  PREPARATIONS 

tration  of  fats,  such  as  bone  marrow   (Henry  J.  Walker).     It  also 
forms  a  good  demulcent  decoction. 

Several   forms  of   seaweeds   are  used   as   food   by   the   Japanese, 
Siamese,  and  Polynesians. 


STARCHY  FOODS  FOR  CHILDREN 

The  best  cereals  and  other  starches  for  children  are  rice,  hominy, 
Indian  meal,  barley,  oatmeal,  cracked  wheat  or  wheaten  grits,  farina, 
cornstarch,  and  sago. 

When  the  cereal  whole  grains  are  used  instead  of  flour,  they  should 
be  soaked  in  cold  water  for  five  or  six  hours  and  then  cooked  for  two 
or  three  hours  in  a  double  boiler.  If  fed  to  infants  less  than  two 
years  of  age  or  to  children  with  any  gastrointestinal  disorder,  they 
should  be  thoroughly  strained.  They  should  be  salted  and  served 
with  cream,  but  without  much  sugar.  The  steamed  preparations 
of  oats,  wheat,  etc.,  which  are  sold  in  market,  may  be  boiled  one 
hour,  and  otherwise  treated  as  the  grains. 

Bread  and  crackers  may  be  allowed  to  infants  after  the  first 
year,  but  only  with  their  meals.  The  bread  always  should  be  porous, 
well  baked,  and  stale.  It  may  be  toasted,  or  given  dry  in  milk,  or 
moderately  buttered.  Zwieback  and  plain  rusk  are  also  good  foods 
for  young  children. 

Crackers  are  made  in  great  variety  for  children  who  have  passed 
the  second  year.  They  should  not  be  too  dry  or  hard.  They  may 
be  eaten  in  milk  or  with  beef  juice,  or  separately,  with  meals  only. 
The  best  are  those  made  of  wheaten  or  Graham  flour,  or  oatmeal. 

DIASTASE,   MALT  EXTRACTS,   ETC. 

Diastase  is  a  vegetable  ferment  which  has  the  property  of  convert- 
ing starchy  foods  into  a  soluble  material  called  maltose.  It  is 
soluble  in  water  and  weak  alcohol,  insoluble  in  stronger  alcohol.  Its 
advantage,  as  compared  with  similar  ferments  in  the  saliva  and  pan- 
creatic juice,  is  considerable,  and  its  strength  enables  it  to  dissolve 
starches  when  present  in  the  proportion  of  only  1  to  2,000.  Like  the 
above-named  ferments,  it  acts  in  alkaline  solution,  but,  unlike  them, 
it  continues  to  operate  in  acid  media;  hence  its  action  is  not  dis- 
turbed by  the  gastric  juice.  Diastase  is  the  peculiar  substance  which 
.causes  the  ripening  during  germination  of  fruits  and  vegetables  by 
converting  iheir  starches  into  dextrins  and  sugars. 

When  malt   is  added  to  a  pease  pudding  or  other  mashed  vege- 


VEGETABLE  FOODS  189 

table,  it  separates  the  mass  into  a  paste  of  cellulose  and  vegetable 
casein,  with  a  supernatant  solution  of  dextrin. 

The  use  of  malt  flour  with  cereal  foods  renders  them  more  di- 
gestible. Malt  flour  alone  is  too  sweet,  but,  added  in  the  propor- 
tion of  one  part  to  four  or  eight  of  oatmeal,  it  makes  an  excellent 
light,  thin  porridge  for  invalids. 

A  variety  of  malt  extracts  and  malted  foods  are  prepared  for  in- 
valids, and  many  of  them  possess  intrinsic  value  for  nutrition  and 
tonic  action.  They  are  especially  useful  in  chronic  and  subacute  ail- 
ments and  convalescence  from  protracted  fevers.  They  are  beneficial 
in  tuberculosis,  caries,  chronic  sepsis,  neurasthenia,  typhoid  fever,  and 
to  some  extent  they  may  be  used  as  beverages  to  replace  the  stronger 
malt  liquors,  ale,  beer,  etc.,  for,  according  to  Leeds,  they  always 
contain  above  3  per  cent  of  alcohol. 

Malted  foods  are  deficient  in  fats  and  protein.  Farinaceous 
meal  of  any  kind  mixed  with  one-eighth  of  its  weight  of  ground 
malt  forms  a  highly  digestible  combination.  Even  20  per  cent  of 
meal  may  be  used,  and  the  preparation  still  remains  fluid  (Eoberts). 

Kepler's  Extract  of  Malt  is  given  in  the  dose  of  a  teaspoonful 
after  meals  in  milk  or  soda  water,  or  it  may  be  spread  upon  any  form 
of  starchy  food. 

Loeflund's  Malt  Extract  is  given  in  doses  of  a  dessertspoonful 
after  meals  in  a  gobletful  of  milk. 

Maltine  is  made  from  three  cereals  —  barley,  wheat,  and  oats.  It 
is  rich  in  diastase.  It  may  be  added  in  equal  part  to  wheat  or  barley 
flour  which  has  been  previously  boiled  in  water,  and  the  mixture 
may  be  used  as  a  diluent  of  milk.  Maltine  may  be  taken  after  meals, 
either  plain  or  added  to  cod-liver  oil,  coca  wine,  pancreatin,  hypo- 
phosphites,  etc.,  for  use  in  tuberculosis  and  other  diseases. 

Hoff's  Malt  Extract  is  given  in  doses  of  a  wineglassful  or  more 
with  meals  for  adults,  and  one  or  two  tablespoonfuls  for  children. 
It  contains  considerable  diastase,  a  minimum  of  alcohol  (about  2 
per  cent),  and  is  said  to  be  free  from  noxious  ingredients.  It  may  be 
drunk  warmed,  with  a  lump  of  sugar  added,  as  a  soothing  draught 
to  allay  cough.  If  desirable  for  feeble  stomachs,  it  may  be  diluted 
with  water  or  soda  water. 

Trammer's  Diastatic  Extract  of  Malt  is  composed  of  the  soluble 
ingredients  of  Canada  barley  malt.  It  is  of  a  sirupy  consistence 
and  has  a  sweetish  flavor.  The  sweetness  may  be  lessened  by  dilution 
with  water,  or  hot  milk.  It  is  advisable,  if  the  stomach  is  feeble,  to 
give  teaspoonful  doses  at  first,1  to  be  increased  to  a  tablespoonful  three 
times  a  day  after  meals. 


190         FOODS  AND  FOOD  PREPARATIONS 

Pancreatic  extract  or  three  to  five  grains  of  pancreatin  with  five 
grains  of  sodium  bicarbonate  may  be  added  to  a  cupful  of  thick,  well- 
boiled  farinaceous  gruel  of  any  sort  —  oatmeal,  cornstarch,  etc. — 
and  if  kept  at  100°  F.  for  a  few  minutes,  the  mass  is  soon  liquefied 
and  made  digestible.  The  hydrated  starch  has  been  converted  into 
dextrin  and  sugar.  There  is  little  or  no  alteration  produced  in  flavor, 
and  if  starch  is  to  be  given  to  an  infant  under  a  year  old  for  any 
purpose,  it  may  be  prepared  in  this  manner. 

Vegetable  Food  in  General 

Vegetable  food  eaten  in  large  quantity  increases  the  elimination 
of  carbon  dioxide  from  the  lungs.  It  also  makes  the  urine  alkaline 
and  intensifies  the  alkalinity  of  other  secretions.  The  urine  of  her- 
bivorous animals  is  normally  alkaline  when  they  are  well  fed,  but 
during  prolonged  fasting  it  becomes  acid. 

The  chief  vegetable  proteids  are  vegetable  albumin,  vegetable 
casein  or  legumin,  and  gluten.  The  latter  predominates  in  the  cerea- 
lia,  and  the  legumin  is  principally  found  in  pulses.  These  proteids 
are  less  rich  in  nitrogen  than  the  corresponding  animal  albuminates. 

Many  vegetables  contain  tough  cellulose,  and  at  best  not  over  50 
per  cent  of  this  material  is  digested  and  assimilated  in  man,  although 
the  lower  animals  derive  much  more  nutriment  from  it. 

A  purely  vegetable  diet  is  not  economical  for  a  laboring  man, 
for  the  reason  that  to  derive  sufficient  nitrogenous  substance  from  it 
he  must  either  obtain  the  very  best  and  most  expensive  cereals  or 
legumes,  or  he  must  eat  a  very  large  quantity  of  vegetables.  (See 
Vegetarianism,  p.  33.)  By  the  addition  of  albuminous  food  or  fat 
to  his  diet  he  saves  both  expense  and  wear  and  tear  of  his  digestive 
organs.  If  unable  to  obtain  fresh  meat,  he  may  employ  for  this 
purpose  milk,  bacon,  lard,  dried  fish,  such  as  herring  or  cod.  Among 
vegetable  foods  oatmeal  and  beans  will  furnish  him  with  the  largest 
available  proportion  of  nitrogenous  material.  Vegetables,  except 
those  which  are  really  seeds,  such  as  those  of  the  leguminosae  or 
pulses,  contain  little  fat. 

A  strict  classification  of  vegetables  is  difficult  in  these  pages. 
For  example,  green  corn  is  a  green  vegetable,  but  it  is  more  con- 
veniently described  in  connection  with  cornmeal,  samp,  etc.,  among 
the  cereals.  (Sec  Corn.  p.  181.)  Certain  vegetables  are  classed  as 
"  green  vegetables,"  meaning  the  lighter  weight  vegetables  which 
contain  con-iderable  earthy  salts  and  comparatively  little  starch,  like 
spinach  and  lettuce,  in  distinction  from  heavy  vegetables  which  con- 
tain much  starch,  like  potatoes,  beans,  etc.  The  former  term  is  used 


VEGETABLE   FOODS  191 

to  describe  fresh  garden  vegetables  of  all  kinds  in  distinction  from 
those  which,  like  potatoes  or  onions,  may  be  kept  for  some  days  or 
weeks  without  spoiling.  The  name  is,  however,  too  vague  for  ac- 
curate description. 

"  Greens "  is  the  common  name  given  to  such  vegetables  as 
spinach,  lettuce,  beet  tops,  etc.,  which  contain  much  chlorophyll  and 
little  starch  or  sugar,  and  which  are  eaten  soon  after  being  taken 
from  the  garden. 

A  simple  division  of  vegetables  for  patients  is  (a)  those  the  edible 
portions  of  which  grow  above  ground  and  (&)  those  which  grow 
below  ground.  With  few  exceptions,  like  the  legumes,  corn,  and 
cabbage,  the  heavier  vegetables  —  i.  e.,  those  which  require  more 
digestive  power,  and  which  contain  abundant  starch  or  sugar  —  grow 
below  ground,  or  are  tubers.  Those  which  grow  above  ground  are 
more  digestible  when  fresh  and  young.  Celery,  however,  is  not  a 
tuber,  is  not  especially  starchy,  and  yet  grows,  in  chief  part,  at  least 
as  eaten,  beneath  the  earth ;  hence  it  is  best  in  all  important  cases  to 
specify  by  name  the  individual  vegetables  which  may  be  partaken  of 
rather  than  to  describe  them  in  general  classes. 

Many  vegetables,  in  themselves  difficult  of  digestion,  may  be 
made  less  so  by  conversion  into  well-cooked  purees,  or  their  extracts 
used  for  flavoring  broths  and  soups  for  invalids.  Generally  speak- 
ing, dried  vegetables  are  much  less  digestible  than  when  fresh.  They 
become  hard,  stringy,  and  tasteless. 

The  following-named  vegetables  are  those  in  common  use  which 
contain  the  largest  percentage  of  both  starches  and  sugars:  Pota- 
toes (both  white  and  sweet),  yams,  beans,  lentils,  corn,  peas,  carrots, 
parsnips,  beets,  turnips. 

Vegetable  foods  which  are  somewhat  stimulant  or  pungent  in 
their  action  are  leeks,  onions,  garlic,  herbs  in  general,  mustard, 
peppers,  cresses,  mints,  asparagus,  and  radishes.  They  increase  the 
secretion  of  the  saliva  and  gastric  juice,  and  several  are  somewhat 
diuretic. 

Some  vegetables  are  laxative  on  account  of  their  special  chemical 
composition.  Such,  for  example,  are  spinach,  tomatoes,  and  most 
green  vegetables  when  fresh  and  well  cooked.  Some,  like  cucum- 
bers, and  tomatoes,  are  laxative  from  the  seeds,  or,  like  old  corn, 
squash  and  celery,  from  the  indigestible  residue  which  they  contain. 
The  heavier  vegetables,  such  as  peas,  beans,  beets,  turnips,  potatoes, 
etc.,  are  liable  to  be  constipating,  although  they  aid  normal  peristalsis 
in  that  class  of  cases  in  which  the  diet  has  been  previously  mainly 
nitrogenous.  (See  Dietetic  Treatment  of  Constipation.) 


192 


FOODS  AND  FOOD  PREPARATIONS 


Vegetables  which  have  a  special  antiscorbutic  reputation  are  cab- 
bage, tomatoes,  and  all  those  used  for  fresh  salads.  These  also  yield 
calcium  oxalate  in  the  urine. 

All  vegetables  which  are  eaten  raw  should  be  washed  thoroughly 
beforehand;  otherwise  they  may  be  contaminated  with  manure  and 
other  impurities,  or  the  excrement  of  domestic  animals  which  have 
been  roaming  in  the  garden.  The  larvae  of  both  tapeworms  and 
roundworms  have  been  transmitted  to  man  in  this  manner.  Water 
from  foul  wells  is  used  sometimes  for  sprinkling  gardens,  and  it  is 
possible  for  typhoid,  cholera,  or  ether  noxious  germs  to  be  spread 
by  this  means  when  the  vegetables  are  eaten  raw. 

LEGUMES 

Peas,  Beans,  Lentils,  Peanuts. —  Legumes  rank  next  to  cereals  in 
importance  as  vegetable  food.  In  middle  and  northern  Europe 
among  legumes  peas  are  preferred,  but  in  Mediterranean  countries 
the  use  of  beans  and  lentils  predominates.  In  this  country  both  peas 
and  beans  are  extensively  eaten,  the  Jentil  very  little.  Owing  to  the 
exceedingly  leathery  external  envelope  which  they  possess  when  old, 
legumes  are  very  indigestible  unless  cooked  for  a  long  time,  and  if 
dried  they  require  previous  prolonged  soaking  in  cold  water,  for 
drying  diminishes  their  size  and  makes  them  extremely  tough. 
Fresh  legumes  contain  much  water,  and  in  percentage  composition 
resemble  the  cabbage.  They  also  contain  much  protein,  carbohy- 
drates, and  a  little  fat. 

Percentage  Composition  and  Heats  of  Combustion  of  Dry  Legumes. 
(Chas.  E.  Wait.) 


Water. 

Protein 
(NX6.25) 

Fat. 

Carbohy- 
drates. 

Ash. 

Heat  of 

combustion 
per  gram. 

Beans,  kidney  

Per  ct. 
11.25 

Per  ct. 

25.38 

Per  ct. 
1.41 

Per  ct. 
58.38 

Per  ct. 
3.58 

Calories. 

Beans    white 

11.21 

18.25 

1.63 

64.89 

4.02 

3.885 

Cowpeas,  lady    

11.32 

25.50 

1.73 

57.88 

3.57 

4.023 

The  proteid  substance  von  Liebig  called  "  plant  casein,"  from  its  re- 
semblance to  casein  of  milk.  It  differs  from  the  proteid  gluten  of 
grains  and  will  not  form  dough.  The  percentage  of  protein  in 
legumes  exceeds  that  of  the  best  beef  (M.  H.  Abel).  Although  the 
legumes  contain  so  large  a  percentage  of  protein,  it  is  by  no  means 
all  assimilated.  Hoffman  found  that  nearly  one-half  of  the  protein 
of  lentils  passed  off  in  the  feces,  being  unabsorbed.  Striimpell  found 


VEGETABLE  FOODS  193 

that  40  per  cent  of  the  protein  of  whole  beans  —  i.  e.,  with  the  skins 
intact  —  is  undigested;  but  when  made  into  flour  only  8.2  per  cent 
of  protein  was  unabsorbed,  the  latter  corresponding  with  the  digesti- 
bility of  meat  protein.  In  Buhner's  experiments  with  dried  peas 
28  per  cent  of  the  proteid  was  lost  in  the  feces. 

Legumes  are  liable  to  induce  intestinal  fermentation,  with  exces- 
sive and  often  annoying  production  of  gas  (methan),  hence  they  are 
not  available  as  the  sole  article  of  diet.  If  eaten  as  an  exclusive 
food,  eighteen  ounces  of  dried  peas  or  beans,  making  six  pints  of 
thick  soup,  would  have  to  be  consumed  daily  (M.  H.  Abel). 

Dried  "  split "  peas  have  had  the  external  envelope  removed,  and 
they  may  be  made  into  nutritious  purees.  The  tough  external  coats 
of  old  peas  may  often  be  found  unaltered  in  the  feces. 

Fresh  very  young  green  peas,  petit  pois,  are  easily  digested,  and 
may  occasionally  be  allowed  in  a  convalescent  dietary,  but  old  and 
tough  legumes  require  more  mastication  than  meat. 

The  Cou'pea  is  especially  recommended  as  a  food  for  man  in  a  study 
of  the  legumes  made  at  the  University  of  Tennessee  in  1907  by 
Prof.  Charles  E.  Wait.  He  finds  their  nutritive  value  equal  to 
wheaten  bread;  they  have  a  distinctive  agreeable  flavor,  and  they 
have  long  been  used  in  the  Southern  States. 

The  legumes  are  often  cooked  with  pork,  which  adds  to  the  per- 
centage of  fat  in  this  form  of  food.  Baked  beans  are  cooked  in  this 
way,  and  also  pea  soup;  the  swelling  starch  granules  mingle  with 
the  melting  fat  of  the  pork  and  make  the  dish  more  palatable 
as  well  as  much  more  digestible  than  when  this  fat  is  added  to  meat 
in  the  form  of  croquettes  or  mince,  when  it  merely  smears  the  out- 
side of  the  larger  particles  of  food. 

Erbswurst,  or  pea  sausage,  was  introduced  some  years  ago  in  the 
German  army.  It  was  invented  in  1870  by  a  cook  named  Griinberg, 
and  the  German  Government  bought  the  secret  of  its  preparation. 
It  is  a  cooked  food  composed  of  pea  meal  mixed  with  fat  pork  and 
salt,  so  treated  as  to  prevent  the  decay  of  legumin.  It  is  highly  nu- 
tritious, for  the  peas  contain  a  large  proportion  of  protein  as  well 
as  starchy  material,  and  the  fat  furnishes  energy,  but  as  a  diet 
it  soon  becomes  monotonous,  and  not  infrequently  produces  flatu- 
lence and  diarrhoea,  for  which  the  legumes  are  noted.  The  flatu- 
lence is  caused  by  liberation  of  sulphuretted  hydrogen  from  legumin. 

Erbswurst  may  be  made  readily  into  soups.     It  figured  largely 

in  the  Franco-Prussian  War,  and  was  known  as  the  "iron  ration." 

A  powdered   "  pea  soup "  may  be  obtained  which  is  composed  of 

powdered  peas  and  extracts  of  beef  with  salts  and  herb  extracts  for 

15 


194 


FOODS   AND   FOOD   PREPARATIONS 


flavoring.  A  three-and-a-half-ounce  package  contains  in  grams: 
proteids,  21 ;  fats,  17.25 ;  carbohydrates,  46.5.  It  is  excellent  for 
army  service  in  the  field. 

Percentage  Composition  of  Some  Prepared   Military  Pea  Foods    (Woodruff). 


Water. 

Pro- 
tein. 

Fats. 

Carbo- 
hydrates 

Wood 
fibre. 

Ash. 

Authority. 

Erbswurst                       .  .  . 

12.09 
7.58 
8.08 

4.78 

31.18 
16.93 
15.81 

21.09 

3.08 
8.98 
24.41 

17.25 

47.50 
53.44 
36.78 

46.45 

6.15 
11.73 
13.53 

6.03 

Blythe 
Konig 

S.P.Sharpless 

Dried  pea  soup    (  1  )     ... 
"       "        (2)    ... 
Kopf's  "        "       (used  by 
the  English  army)    .  . 

1.34 
1.69 

4.40 

Penzoldt  has  succeeded  in  obtaining  predigested  vegetable  albu- 
min by  the  following  receipt: 

Finest   pea   meal    25.0  grams. 

Pepsin     0.5  gram. 

Salicylic  acid 1.0       " 

Mix  and  let  stand  at  100°  F.  for  twenty-four  hours;  strain. 

The  fluid  retains  the  taste  of  pea  soup,  and  is  quite  free  from 
starch.  It  may  be  added  to  meat  extracts  or  eggs,  and  may  be 
flavored  with  salt,  pepper,  and  spices. 

Haricots  or  kidney  beans  constitute  a  very  serviceable  article  of 
diet,  being  one  of  the  cheapest  and  best  of  all  the  pulses.  These 
beans  should  be  soaked  thoroughly  until  swollen  and  soft  before  boil- 
ing, and  should  be  eaten  only  when  tender.  Their  flavor  is  height- 
ened by  the  addition  of  a  little  onion,  parsley,  or  other  aromatic 
vegetable,  and  their  nutritive  value  is  increased  by  cooking  with 
pork. 

Fresh,  young,  and  tender  string  beans  are  very  digestible. 

Young,  fresh  Lima  beans  are  wholesome  and  very  nutritious,  but 
if  old  they  are  indigestible.  The  same  is  true  of  butter  beans. 

The  red  bean  of  the  tropics,  which  is  largely  used  in  the  Mexican 
army  ration,  is  less  prone  to  cause  diarrhoea  than  the  dry  domestic 
white  bean :  but  it  has  a  more  tender  skin,  is  therefore  less  easily 
transported,  and  it  absorbs  moisture  so  rapidly  that  it  is  liable  to 
ferment. 

The  frijolc  is  a  small,  flat,  reddish-brown  bean  much  eaten  in 
Mexico  and  neighboring  portions  of  the  United  States. 

The  *o//<7  bean  is  the  chief  legume  of  China  and  Japan,  where 
it  furnishes  the  necessary  protein  to  add  to  a  rice  diet.  From  its 
vegetable  casein  several  varieties  of  bean  cheese  are  made.  (Page 
181.) 


195 


Lentils. —  Lentils  are  much  cultivated  in  the  south  of  France,  and 
also  near  Paris.  They  are  usually  dried  and  split,  in  which  condition 
they  make  a  nutritious  soup.  They  are  used  more  on  the  Continent 
of  Europe  than  in  this  country,  and  they  are  eaten  in  England, 
usually  in  the  form  of 
puree.  Lentil  flour  con- 
tains twice  as  much  pro- 
tein as  that  of  oats  or 
wheat,  and  nearly  twice 
as  much  lime  (Rob- 
erts). The  Hindoos 
rely  upon  the  lentil  for 
its  staying  power  when 
undertaking  arduous 
journeys. 

Lentils  are  sold  un- 
der the  name  of  "  rev- 
alenta  Arabica "  of 
which  they  form  an 
ingredient  (p.  186). 
Their  taste  is  somewhat 
bitter,  and  on  that  ac- 
count, unless  disguised 
by  some  vegetable  fla- 
vor, they  may  be  dis- 
liked. Like  the  other 
legumes,  they  contain 
protein  and  fat,  and  are 
nutritious  (Fig.  34). 

Peanuts.  —  The  pea- 
nut is  not  a  nut  at  all, 
but  a  legume  growing 
at  the  surface  of  the 
ground.  It  resembles  nuts,  however,  in  its  large  content  of  fat  —  50 
per  cent. 

Peanuts  are  nutritious,  but  indigestible  when  roasted  whole.  Pea- 
nut flour  is  made  from  the  ground  and  bolted  nuts,  and  it  is  claimed 
that  a  pound  of  it  contains  as  much  nutritive  material  as  three 
pounds  of  beef  or  two  of  peas.  The  peanut  grits  may  be  boiled  like 
oatmeal  or  made  into  biscuits.  Experiments  have  been  made  with 
the  view  of  possible  introduction  of  this  food  into  the  German 
army  to  be  used  like  erbswurst  (p.  193).  Peanuts  contain  consider- 


FIG.  34. —  LENTIL. 
(Mary  H.   Abel,   Farmers'   Bui.,   No.    121.) 


196          FOODS  AND  FOOD  PEEPAEATIONS 

able  oil,  which  is  extracted  and  sold  largely  as  spurious  olive  oil. 
It  is  also  sometimes  used  in  the  preparation  of  oleomargarine,  and 
the  roasted  nuts  themselves  make  a  sort  of  imitation  coffee.  A 
form  of  peanut  meal  is  prepared  for  diabetics  which  is  said  to  con- 
tain little  or  no  carbohydrate.  Pancakes  may  be  made  from  it.  The 


FIG.  35. —  PEANUT. 
(Mary  H.  Abel,  Farmers'  Bui.,  No.   121,   1900.) 

meal  contains  52  per  cent  of  protein,  27  per  cent  of  carbohydrates, 
and  8  per  cent  of  fat.  Four  million  bushels  of  peanuts  are  raised 
annually  in  the  Southern  United  States. 

ROOTS  AND  TUBERS 

Eoots  and  tubers  constitute  a  very  important  class  of  vegetable 
foods.  They  contain  both  starch  and  sugar  as  well  as  a  little  pectin 
and  potash  salts.  They  have  much  less  albuminous  material  than  is 
to  be  found  in  any  other  forms  of  starchy  food,  and  they  also  hold 
a  large  percentage  of  water.  Many  of  them  are  nutritious  and 
fattening,  but  in  proportion  to  their  bulk  they  afford  less  actual 
nutriment  than  either  legumes  or  cereals. 

Potatoes. —  The  potato  ranks  first  in  importance  among  the  class 
of  tubers  which  serve  man  for  food,  both  on  account  of  its  easy  cul- 


VEGETABLE  FOODS  197 

tivation  in  a  great  variety  of  soils  and  on  account  of  its  digesti- 
bility when  properly  cooked.  As  an  exclusive  article  of  diet  the 
potato  is  composed  too  largely  of  starch  to  be  of  much  nutritive 
value,  and  several  pounds  a  day  would  have  to  be  eaten  to  supply 
enough  nitrogen  for  the  energy  of  the  body.  The  potato,  however,  has 
less  starch  than  rice,  peas,  or  lentils.  It  also  has  less  woody  fibre  than 
most  underground  vegetables.  In  Ireland  this  vegetable  constitutes 
a  greater  proportion  of  the  daily  food  than  in  almost  any  other 
country,  and  in  periods  of  famine  has  been  known  to  form  four- 
fifths  of  the  entire  food  for  a  time,  but  of  late  years  it  has  been 
supplemented  largely  by  the  cultivation  of  Indian  corn  and  other 
products.  The  flavor  and  quality  of  the  potato  is  influenced  very 
much  by  the  soil  and  climate  in  which  it  

-,  -ll-l  ^SALT 

grows,  a  sandy  soil  being  best.  /    PRQTUN      "\ 

Konig  gives  the  percentage  composi-  /  CARBOHYDRATES\ 

tion  of  the  potato  as  water,  75.77 ;  nitro-         ^ » 

genous  materials,  1.79  (others  give 
2.10)  ;  fat,  1.60;  starch,  20.56;  cellulose, 
0.75;  ash,  0.97.  It  is  thus  seen  to  con- 
tain about  one-fourth  solid  material. 

The  potato  becomes  a  much  more 
strengthening  food  when  eaten,  as  it 
usually  is,  with  meat,  gravy,  fat,  or  but- 
ter and  salt. 

Potato  juice  has  $  faintly  acid  reac- 
tion, and  its  vegetable  acids  are  combined 

mainly  with  salts  of  potassium,  but  also       OF    INGREDIENTS.     There    is 

..,         ,.  T        -.    .  TJ.     i  also  a  faint  trace  of  fat. 

with  sodium  and  calcium.     It  also  con- 
tains traces  of  iron,  phosphoric  and  sulphuric  acids,  chlorine,  silica, 
and  magnesia. 

Owing  to  the  comparatively  large  proportion  —  from  15  to  24  per 
cent  —  of  nearly  pure  starch  which  is  found  in  the  potato,  it  is  ex- 
tensively used  in  this  country  and  elsewhere  for  the  manufacture  of 
laundry  starch.  Old  potatoes,  and  those  which  have  been  kept  long, 
show  some  alteration  in  the  quantity  of  their  starch,  and  a  part  is 
converted  into  sugar  and  gum. 

Potato  starch,  as  compared  with  other  starches,  is  thoroughly  di- 
gestible, but  much  depends  upon  the  cooking.  The  starchy  gran- 
ules are  tough  and  absorb  water  from  the  acid  juices  which  surround 
them  and  from  water  added  in  cooking,  and  when  properly  prepared 
the  potato  becomes  soft  and  mealy.  When  this  is  not  the  case,  how- 
ever, it  remains  hard,  "  soggy,"  and  quite  indigestible. 


198         FOODS  AND  FOOD  PREPARATIONS 

The  following  statement  in  regard  to  the  potato  is  made  in  a  re- 
port of  the  British  Commissioners  of  Prisons : 

"  Within  and  surrounding  the  cells  is  a  fluid  or  juice  the  albumi- 
nous constituents  of  which  are  coagulated  during  the  process  of 
cooking.  The  watery  part  of  this  juice  is  absorbed  by  the  starch 
granules,  which  swell  up  and  distend  the  cells  in  which  they  are  con- 
tained, so  that  they  no  longer  adhere  together,  and  the  result  is  the 
loose  flocculent  mass  which  is  described  as  a  floury  or  mealy  potato. 


FIG.  37. —  POTATO  STARCH  AS  IT  APPEARS  UJTDER  THE 

MICROSCOPE. 
(U.  S.  Dept.  of  Agri.,  Bui.  56,  Office  of  Expt.  Stations.) 

Unless  the  potato  be  cooked  .properly,  the  fluid  referred  to  is  only 
partially  absorbed,  the  cells  do  not  become  sufficiently  distended  and 
separated,  and  the  potato  is  then  described  as  '  waxy '  and  '  dense.' '' 

\Yhen  potatoes  are  cooked  in  water,  it  is  desirable  not  to  remove 
their  skins,  for  the  latter  prevent  to  -a  great  extent  the  passage  of 
the  salts  out  into  the  fluid.  The  fact  that  potatoes  will  not  decay  if 
kept  drv  for  a  length  of  time  makes  them  very  useful  vegetables 
upon  sea  voyages,  when  their  antiscorbutic  properties  are  especially 
serviceable. 

Potatoes  are  more  digestible  when  cooked  by  baking  in  their 
skins  than  by  any  other  process.  They  then  become  mealy  and  their 
starch  is  digested  with  comparative  ease  by  invalids.  They  are  also 


VEGETABLE   FOODS  199 

quite  digestible  if  steamed,  or  if  boiled  and  mashed  through  a 
colander. 

Potatoes  should  be  avoided  in  all  cases  of  feeble  digestion  unless 
they  are  perfectly  mealy  and  crumble  readily,  and  this  quality  de- 
pends not  alone  upon  the  method  of  cooking,  but  upon  the  nature  of 
the  potato  itself,  which  varies  according  to  the  soil  or  the  season  of 
the  year  in  which  it  has  been  grown.  Very  young  potatoes  are  not 
mealy.  They  require  more  cooking  and  are  less  digestible  than 
those  of  medium  age.  If  too  old,  on  the  other  hand,  potatoes  be- 
come waxy  and  equally  undesirable.  If  they  have  been  exposed  to 
frost  or  have  been  cultivated  in  a  damp,  boggy  soil,  their  digestibility 
is  much  impaired. 

Sweet  Potatoes. —  The  variety  known  as  the  sweet  potato  contains 
somewhat  less  starch  than  the  white  potato,  having  only  16  per  cent, 
but  it  has  more  water,  and  a  larger  proportion  of  sugar  —  10  per  cent. 
It  forms  a  valuable  and  decidedly  nutritious  food  which  is  eaten  ex- 
tensively throughout  the  United  States,  but  it  is  not  so  digestible  as 
the  white  potato,  for  it  cannot  always  be  obtained  in  a  mealy  form, 
and  is  sometimes  stringy  and  sodden.  A  flour  or  meal  may  be  pre- 
pared from  it  by  drying.  Its  use  in  Europe  antedates  that  of  the 
white  potato,  which  has  to  a  great  extent  superseded  it.  These  po- 
tatoes vary  much  more  in  flavor  than  do  the  white.  In  general, 
they  should  not  be  given  to  invalids  for  they  are  liable  to  produce  in- 
digestion and  flatulency. 

The  yarn,  another  form  of  tuber,  is  eaten  in  the  tropics  and  in 
some  parts  of  Europe.  It  is  mealy,  but  not  very  sweet,  and  it  con- 
stitutes a  wholesome  food. 

The  Jerusalem  artichoke,  or  ground  pear,  is  a  tuber  belonging  to 
the  sunflower  family,  which  was  originally  introduced  from  Brazil. 
It  is  used  more  commonly  in  England  than  elsewhere,  but  is  also 
sometimes  cultivated  in  the  United  States.  It  is  sweet  and  watery, 
for  it  contains  little  starch,  and  is  not  "  mealy  "  when  cooked.  It 
contains  more  sugar  than  the  sweet  potato,  having  14  per  cent  of 
sugar,  3  per  cent  of  protein,  and  2  per  cent  of  inulin.  Its  nutritive 
value  is  comparatively  slight,  but  it  is  easily  digested. 

Beets. —  The  beet  contains  among  its  solids  between  85  and 
90  per  cent  of  starches  and  sugars,  a  trace  of  salts,  and  somewhat 
over  1  per  cent  of  protein.  It  is  a  common  source  of  sugar,  which 
when  refined  is  somewhat  less  sweet  than  cane  sugar,  but  is  other- 
wise as  good.  On  account  of  the  sugar  which  they  contain,  beets 
have  the  reputation  of  contributing  to  the  formation  of  fat  in  the 
body.  Young,  tender  beets  are  very  nourishing,  and  they  are  often 


200          FOODS  AND  FOOD  PREPARATIONS 

eaten  in  the  form  of  salads  or  with  vinegar  and  oil,  and  thus  con- 
tribute a  useful  variety  to  the  diet. 

Succulent  Tubers. —  Carrots,  parsnips,  turnips,  salsify,  and  radishes 
constitute  a  group  of  succulent  roots  which  contain  considerable 
watery  juice,  and  on  this  account  are  usually  eaten  fresh,  for  if  kept 
long  they  become  dry  and  less  palatable,  or  are  apt  to  decay;  with 
care,  however,  they  may  be  preserved  in  their  natural  state  for  a 
considerable  period.  They  are  digestible,  and  when  thoroughly 
boiled  are  nutritious. 

Carrots  consist  of  upward  of  85  per  cent  of  water,  with  a  small 
proportion  of  salts,  8  per  cent  of  carbohydrates  with  some  sugar,  and 
about  1  per  cent  of  protein.  The  outer  layers  of  the  carrot  contain 
a  material  called  pectin  that  may  be  obtained  as  a  jelly  and  mixed 
with  fruit  or  meat  jelly  for  flavoring  invalids'  food. 

Young  carrots,  when  soft  and  friable,  if  boiled  are  very  tender 
and  highly  flavored,  and  constitute  a  nutritious  food.  In  France 
and  Germany  they  are  more  popular  than  in  this  country  and  arc 
cooked  with  other  vegetables,  although  somewhat  at  the  expense  of 
the  flavor  of  the  latter.  At  the  baths  of  Vichy  they  form  a  part  of 
the  daily  breakfast. 

Parsnips  are  a  wholesome,  although  less  used  food  than  carrots. 
The  parsnip  contains  over  90  per  cent  of  water  and  only  6  per  cent  of 
starch  and  sugar,  with  1  per  cent  of  protein,  besides  other  materials. 
It  is  a  rather  strongly  flavored  vegetable,  and  bulky  in  proportion 
to  its  nutritive  value,  but  when  young  and  properly  cooked  by  pro- 
longed boiling  and  seasoning  it  is  a  good  food.  It  should  be  par- 
ticularly avoided  by  those  persons  in  whom  there  is  any  tendency 
to  flatulency,  which,  like  the  legumes,  it  is  apt  to  produce.  It  may 
be  fermented  into  an  alcoholic  beverage. 

Turnips  are  less  nutritive  than  either  carrots  or  parsnips.  They 
should  never  be  eaten  by  the  sick. 

Kohl  rabi,  or  turnip-root  cabbage,  yields  an  above-ground  turnip, 
which  is  somewhat  astringent. 

Salsify,  or  oyster  plant,  is  a  root  which  has  a  mild  'sweet  flavor 
somewhat  similar  to  the  parsnip,  and  is  an  excellent  food  of  easy 
digestibility. 

Radishes,  which  are  not  unlike  turnips  in  composition,  contain  a 
large  percentage  of  water  and  a  comparatively  small  amount  of 
starch.  This  vegetable  is  of  no  special  value  for  nutrition,  and  serves 
chiefly  as  a  relish.  Being  usually  eaten  raw,  it  is  difficult  of  diges- 
tion, and  is  apt  to  produce  eructations.  It  is  rendered  more  digestible 
by  cooking.  Tt  has  some  reputation  as  an  antiscorbutic. 


VEGETABLE   FOODS  201 

GREEN    VEGETABLES 

Composition. —  Green  vegetables  do  not  contain  much  nutriment 
in  comparison  with  cereals  and  tubers,  and  are  useful  mainly  for 
furnishing  a  pleasing  variation  in  diet  and  supplying  a  large  pro- 
portion of  salts  and  some  acids  which  are  believed  to  be  service- 
able in  the  prevention  of  scurvy.  The  various  uses  of  the  salts  have 
been  elsewhere  described  (see  p.  44).  These  vegetables  often  con- 
tain 90  per  cent  or  more  of  water,  which  in  itself  is  useful  to  the 
system  in  many  ways.  They  furnish  only  a  small  quantity  of  proteid, 
which  varies  from  1.5  up  to  4  per  cent.  In  addition,  they  contain 
cellulose,  chlorophyll,  sugars,  gum,  pectin,  and  sometimes  a  little  fat. 
Their  variety  of  taste  depends  upon  the  presence  of  flavoring  ma- 
terials, chiefly  essential  oils.  As  a  rule,  they  have  a  better  flavor, 
and  are  more  digestible  when  young  than  old,  when  they  become  tough 
and  "  stringy "  from  a  relatively  large  percentage  of  cellulose  or 
woody  fiber.  Since  the  green  vegetables  afford  so  little  nutriment 
in  proportion  to  their  bulk,  they  are  not  of  much  service  for  persons 
with  feeble  digestion,  and,  unless  they  are  young  and  tender,  they 
are  positively  harmful  by  overtaxing  the  digestive  system.  On  the 
other  hand,  they  are  very  useful  in  overcoming  constipation  by  their 
bulky  waste  matter,  which  acts  as  a  mechanical  stimulus  to  peristaltic 
action. 

The  digestibility  of  these  vegetables  is  rendered  much  greater  by 
careful  cultivation  in  suitable  soils.  Owing  to  the  large  quantity  of 
water  which  they  hold  (which  readily  evaporates),  they  soon  wilt  or 
become  dry  in  market.  For  the  most  part  they  should  be  eaten  when 
quite  fresh,  although  celery  and  winter  cabbage  form  an  exception, 
as  they  may  be  kept  for  weeks. 

Fresh  green  vegetables  as  well  as  roots  or  tubers  are  always  made 
more  digestible  by  cooking,  which  softens  them.  Their  most  accept- 
able form  for  invalids  is  that  of  purees. 

Varieties  and  Properties. —  Cabbages. —  The  cabbage  family,  which 
belongs  to  the  natural  order  Cruciferce,  furnishes  many  examples 
of  green  vegetables,  some  of  which  are  of  value  for  their  leaves, 
and  others  for  their  modified  flowers.  There  are  about  seventy 
varieties  of  cabbages.  They  contain  considerable  sulphur,  which,  if 
malfermentation  exists  in  the  alimentary  canal,  produces  sulphuretted 
hydrogen,  causing  flatulence  and  unpleasant  odor.  They  may  also 
give  rise  to  calcium  oxalate  in  the  urine,  by  causing  indigestion, 
and  they  should  be  avoided  by  the  rheumatic  or  gouty,  and.  in  fact, 
by  all  classes  of  invalids.  Cabbages  and  other  vegetables  of  this 
16 


202          FOODS  AND  FOOD  PREPARATIONS 

order  impart  a  strong  taste  and  odor  to  the  water  used  for  boiling 
them.  When  soft  and  crisp,  cabbage  is  a  wholesome  food  for  those 
with  strong  digestion,  and  it  has  decided  antiscorbutic  properties 
when  fresh,  which  are  lessened  by  fermentation. 

The  principle  edible  representatives  and  preparations  of  the  cab- 
bage family  are  the  following: 

1.  Sauerkraut  which  is  made  by  placing  salt  between  layers  of 
cabbage  leaves  and  subjecting  them  to  pressure,  which  bruises  them 
and  squeezes  out  their  juices.     The  mass  then  ferments  with  the 
formation  of  organic  acids. 

2.  Cauliflower  and   broccoli  are  the  flowers  of  plants  which  are 
grown  large  and  tender  by  cultivation.     When  boiled  and   served 
with  a  milk  or  butter  sauce  they  are  much  esteemed  for  their  flavor  and 
easy  digestibility  in  healthy  stomachs,  but  they  cause  flatulence  if 
eaten  by  dyspeptics.     These  vegetables  may  be  dressed  with  olive  oil 
and  eaten  as  a  salad.     Cauliflower  is  also  used  as  a  common  ingredient 
of  mixed  pickles. 

Brussels  sprouts  like  the  cauliflower  are  flowers,  and  resemble  it  in 
digestive  properties. 

3.  Cole  is  a  plant  of  the  cabbage  family  which  does  not  "  head." 

4.  Seakale  is  grown  in  the  dark,  so  that  it  has  no  chlorophyll.     It 
is  equally  digestible  with  cauliflower  if  well  bleached.     It  is  more 
often  cultivated  in  England  than  in  this  country. 

Spinach,  beet  tops  or  "greens,"  dandelion  leaves,  and  turnip  tops 
are  all  useful  green  vegetables,  and  of  these  spinach,  which  is  slightly 
acid,  is  the  most  common  and  desirable.  These  substances  afford 
almost  no  nutriment,  and  are  valuable  chiefly  for  their  laxative  action. 
The  mineral  salts  which  they  contain,  especially  those  of  spinach, 
have  been  shown  by  Luff,  of  London,  to  be  of  service  in  gout  in 
increasing  the  solubility  of  sodium  biurate  and  retarding  the  con- 
version of  quadriurates  into  biurates.  (See  Gout.)  If  the  leaves 
are  young  and  tender,  and  if  they  are  cooked  until  they  become 
quite  soft  and  are  then  chopped  into  a  fine  pulp,  they  are  very  whole- 
some articles  of  food  for  the  relief  of  chronic  constipation.  Spinach 
may  be  used  in  tests  to  determine  the  digestibility  and  mobility  of 
the  stomach,  as  it  is  easy  to  recognize  in  the  stomach  contents  when 
undigested.  The  leaves  of  the  common  milkweed  make  an  excel- 
lent substitute  for  spinach,  scarcely  distinguishable  from  it  in  taste. 
Dandelion  leaves  have  a  less  delicate  flavor  than  spinach,  and  are 
said  to  possess  a  slight  diuretic  action.  Unless  bleached  they  are 
bitter.  The  dandelion  root  is  laxative,  like  the  leaves,  and  it  forms 
an  ingredient  of  root-beer. 


VEGETABLE  FOODS  203 

Lettuce,  etc. —  There  is  a  group  of  vegetables  of  which  lettuce  is 
the  chief  type,  the  leaves  of  which  are  eaten  raw.  They  are  useful 
for  their  flavor  and  for  the  variety  which  they  furnish  in  the  course 
of  a  meal.  They  cannot  be  said  to  possess  any  nutrient  value,  but 
they  are  usually  taken  with  vinegar  and  oil,  and  the  latter  is  very 
nourishing.  Since  they  contain  little  starch  and  practically  no  sugar, 
they  may  be  allowed  in  the  diabetic  regimen. 

Sorrel  and  cress,  or  peppergrass,  are  used  in  the  making  of  salads, 
but  less  in  this  country  than  in  Europe.  Sorrel  has  a  somewhat  pun- 
gent or  acid  flavor,  which  is  due  to  acid  oxalates,  and  this  fact  ren- 
ders it  unfit  for  use  by  patients  who  are  subject  to  attacks  of  gout 
and  rheumatism  or  who  have  the  uric-acid  diathesis.  A  fatal  case  of 
sorrel-poisoning  in  a  boy  five  years  of  age  has  been  reported.  To 
quench  thirst,  excited  by  eating  a  quantity  of  sorrel,  he  swallowed 
some  soapy  water,  the  alkali  of  which  produced  a  soluble  oxalate. 
A  quantity  of  oxalic  acid  was  found  in  the  stomach. 

Many  other  substances  besides  those  above  mentioned  are  used  in 
the  making  of  salads  or  pickles  and  as  relishes.  They  are  anti- 
scorbutic and  serve  to  stimulate  the  digestive  secretions  and  give 
a  fillip  to  the  appetite.  Such  are  green  peppers,  capers,  mint,  tar- 
ragon (an  aromatic  Siberian  plant),  parsley,  chervil,  endive,  chicory, 
okra,  rampion  (campanula),  burnet  (pimpernel),  borage,  chive,  na- 
sturtium seeds,  purslane  stems,  and  horse-radish. 

Celery  is  a  wholesome  vegetable  when  cooked  in  milk  until  it  is 
quite  soft;  but  eaten  raw  it  is  stringy,  and,  as  it  has  little  nutri- 
tive value,  its  use  in  that  form  should  be  discarded  by  invalids.  Its 
aromatic  flavor  makes  it  very  popular,  and  it  furnishes  a  useful 
addition  to  a  light  luncheon  with  bread  and  cheese.  It  has  acquired 
an  undeserved  reputation  for  use  in  rheumatism.  In  Germany 
celery  is  regarded  as  indigestible  because  the  root  is  chiefly  eaten, 
instead  of  the  bleached  stalk,  which  is  preferred  in  this  country,  and 
is  much  more  crisp  and  tender.  "  Celery  salt  "  is  an  agreeable  flavor- 
ing substance  for  soups  and  salads.  Various  preparations  are  made 
from  the  plant,  which  are  sold  by  druggists  as  hypnotics.  They  are 
of  no  value. 

Artichokes  are  a  variety  of  thistle.  They  contain  tannin  and  mu- 
cilaginous materials,  but  nothing  of  true  nutrient  power,  although, 
according  to  Moleschott,  they  hold  17.75  per  cent  of  organic  mat- 
ter. 

Green  artichokes  when  tender  and  thoroughly  cooked  are  easily 
digested,  but  their  high  cost  in  this  country  (except  in  California) 
prevents  them  from  being  consumed  otherwise  than  as  an  article 


204         FOODS  AND  FOOD  PREPARATIONS 

of  luxury.  They  may  be  given  to  diabetic  patients.  Eaten  raw, 
as  they  sometimes  are  in  France,  they  are  very  indigestible. 

Tomatoes. —  The  tomato  is  a  vegetable  which  was  introduced  into 
this  country  about  seventy  years  ago,  the  value  of  which  is  becoming 
more  and  more  appreciated.  In  Germany  it  is  still  sold  as  a  fruit  of 
luxury  rather  than  as  a  common  vegetable.  It  is  wholesome  when 
eaten  raw  as  a  salad  with  vinegar  and  oil,  and  forms  a  popular  in- 
gredient of  strong  condiments,  such  as  tomato  catsup.  It  is  refresh- 
ing, slightly  acid,  and  easily  digested.  The  oxalic  acid  which  it  con- 
tains is  said  to  make  it  injurious  in  cases  of  gout  or  the  uric-acid 
diathesis.  The  tomato  is  much  prized  as  a  canned  vegetable  on  ac- 
count of  the  fact  that  it  retains  more  of  its  original  flavor  than  do 
most  vegetables  preserved  by  this  process. 

The  eggplant  is  related  to  the  tomato,  and  like  it  contains  many 
seeds  when  full  grown,  but  it  is  much  less  assimilable,  especially 
when  fried,  and  is  not  a  suitable  food  for  invalids. 

Cucumbers  are  mainly  eaten  raw,  and  they  should  be  young.  Like 
celery,  they  contain  too  much  woody  fiber  to  be  consumed  in  bulk. 
They  are  valuable  for  pickling  in  vinegar  or  in  the  making  of  chow- 
chow,  but  they  are  always  indigestible;  this  is  due  in  great  part 
to  the  large  size  of  the  seeds  which  the  vegetable  contains,  and  it 
should  never  be  eaten  by  any  one  excepting  those  having  vigorous 
stomachs.  Eaten  raw,  even  in  small  quantities,  it  may  produce  vio- 
lent colic  and  diarrhoea. 

Asparagus  is  a  vegetable  possessing  a  very  delicate  flavor,  and 
from  the  fact  that  it  is  among  the  first  of  the  fresh  vegetables  to  ap- 
pear in  the  early  spring  it  is  highly  esteemed.  When  young  and 
tender  it  is  very  digestible,  even  for  invalids.  The  green  asparagus 
contains  more  bitter  and  resinous  principles  than  the  white.  It  has 
been  claimed  that  it  possesses  some  influence  as  a  cardiac  sedative 
as  well  as  aphrodisiac  action,  but  these  properties  are  imaginary.  It 
is,  however,  slightly  diuretic,  and  owes  this  influence  to  a  substance 
called  asparagin,  which  may  be  obtained  in  crystalline  form.  As- 
paragus imparts  a  very  strong  and  disagreeable  odor  to  the  urine 
which  may  appear  within  an  hour  after  it  has  been  eaten,  and 
which  persists  from  twelve  to  twenty  hours.  It  is  caused  by  a  vola- 
tile sulphur  product,  a  methyl  mercaptan,  which  has  been  proved  to 
originate  in  the  intestine  during  digestion,  from  whence  it  is  ab- 
sorbed. 

Rhubarb,  or  "pieplant."  the  stems  of  the  leaves  of  which  are 
oaten  stowed ,  is  an  excellent  vegetable.  The  flavor  is  quite  tart, 
and  the  fiber  is  stringy,  but  thorough  cooking  renders  it  soft  and 


VEGETABLE  FOODS  205 

digestible.  It  is  laxative,  and  is  therefore  useful  in  cases  of  chronic 
constipation,  but  should  not  be  confounded  with  the  medicinal  rhu- 
barb. This  wholesome  vegetable  has  not  received  the  attention  it 
deserves.  In  Germany,  for  instance,  it  is  still  grown  merely  as  an 
ornamental  garden  plant  on  account  of  its  large  showy  leaves.  It 
produces  calcium  oxalate  in  the  urine  if  eaten  in  excess,  and  should 
therefore  be  avoided  in  oxaluria,  gout,  and  rheumatism. 

Pumpkins  and  squash  contain  much  water  and  a  good  deal  of 
coarse  fiber.  Tender  and  young  summer  squash  is  fairly  digestible, 
but  presents  no  special  dietetic  advantages.  The  pumpkin  is  one  of 
the  oldest  vegetables  on  this  continent,  for  it  was  grown  extensively 
together  with  maize  by  the  early  Indian  tribes. 

Vegetable  marrow,  like  the  pumpkin  and  squash,  is  a  gourd.  It 
is  a  succulent  wholesome  vegetable  of  agreeable  flavor.  In  France 
the  young  marrows  are  called  courgettes.  They  may  be  baked, 
boiled  or  stuffed. 

Onions,  garlic,  shallots,  and  leeks,  which  are  edible  both  as  fresh 
vegetables,  and  after  long  keeping,  are  useful  as  condiments  for  fla- 
voring salads,  meat  stews,  and  other  foods.  They  also  are  eaten 
independently  for  their  nutritive  properties,  which  are  somewhat 
greater  than  those  of  the  four  or  five  vegetables  last  considered. 
Tender  young  leeks  and  white  onions  boiled  and  served  with  milk  or 
cream  are  very  wholesome  and  of  delicate  flavor.  They  possess,  in 
common  with  the  other  green  vegetables,  a  moderate  laxative  action, 
and  are  antiscorbutic.  They  impart  a  strong  typical  odor  to  the 
breath,  which  appears  within  two  or  three  hours,  and  if  constipa- 
tion exists,  persists  for  twenty-four  hours  or  more.  This  is  due 
to  volatile  substances  which  are  absorbed  by  the  blood  from  the 
alimentary  canal  and  carried  to  the  lungs,  where  they  are  lib- 
erated. 

Taro  or  tania  is  a  nutritious  vegetable  grown  in  the  Polynesian  Is- 
lands and  to  a  limited  extent  in  the  southern  United  States.  It  is  of  a 
purple  color,  and  root,  leaves,  and  stalk  are  all  eaten  boiled.  It  is 
fermented  to  produce  the  "  poi "  of  the  Sandwich  Islands. 

Cranberries  are  really  more  of  a  fruit  than  a  vegetable,  but  they 
are  usually  eaten  with  meat  as  a  vegetable.  They  are  serviceable 
for  their  agreeable  acidity  and  flavor,  but  unless  very  thoroughly 
cooked  and  made  into  a  jelly  with  much  sugar,  they  are  indigestible, 
for  their  outer  coatings  are  extremely  tough.  They  should  never  be 
given  to  invalids. 

The  composition  of  some  common  vegetables  is  tabulated  by  C.  F. 
Langworthy  as  follows: 


206 


FOODS   AND   FOOD   PREPARATIONS 
Composition  of  Vegetables    (Edible   Portion). 


Water. 

Protein. 

Fat. 

Carbohy- 
drates. 

Calories 
per  Ib. 

Beans,   dried    

12.6 

22.5 

1.8 

59.6 

1  520 

Beans,   Lima      

Beans     string            .          

830 

2  1 

3 

6  9 

17O 

Beets    

70.0 

1.3 

.1 

7.7 

160 

Cabbage       

77.7 

1.4 

.2 

4  8 

HT 

Celery    

75.6 

.9 

.1 

2.6 

65 

Corn,  green   (sweet),  edible  por- 
tion         

75.4 

3.1 

1  1 

19  7 

44O 

Cucumbers    

81.1 

.7 

.2 

2.6 

65 

Lettuce    

80.5 

1.0 

.2 

2.5 

65 

Mushrooms  

88.1 

3.5 

.4 

6.8 

185 

Onions   

78.9 

1.4 

.3 

8.9 

190 

Parsnips    

66.4 

1.3 

4 

10  8 

23fl 

Peas    (Pisum   sativum)     

74.6 

7.0 

0.5 

16.9 

440 

Potatoes    

62.6 

1.8 

.1 

14  7 

295 

Rhubarb    

56.6 

.4 

4. 

2  2 

fin 

Sweet  potatoes    

55.2 

1.4 

.6 

21  9 

440 

Spinach   

92.3 

2.1 

3 

3  2 

QK 

Squash    

44  2 

7 

2 

4  ^ 

inn 

Tomatoes    

94  3 

9 

4 

^  Q 

inn 

Turnips 

62  7 

9 

1 

57 

I9n 

Vegetables  Classified  According  to  Their  Dietetic  Value. 
1.  Useful  for  nutriment,  mainly  protein,  but  also  starch  and  fats: 
White  beans.  Red  beans. 

Frijole. 

(haricots).  Peas   (dried  and  split,  or  fresh), 

Lentils. 
Peanuts. 


Lima  beans. 
Kidney  beans 
Soya  beans. 
French  beans. 


2.  Useful  for  nutriment,  mainly  for  starch  and  sugar: 
White  potatoes.  Jerusalem  artichokes. 
Sweet   potatoes.  Beets. 

Yams.  Corn. 

Artichokes. 

3.  Useful  for  variety  of  flavor,  as  antiscorbutics,  and  to  add  bulk  of  undi- 
gested fibrous  tissue  to  the  feces  in  cases  of  chronic  constipation: 


Carrots. 

Parsnips. 

Turnips. 

Kohl   rabi. 

Salsify    (oyster  plant). 

Radishes. 

Cabbages    (including   cole,   seakale, 

and    sauerkraut). 
Cauliflower. 
Broccoli. 
Spinach. 
Beet  tops. 
Turnip    tops. 
Dandelion  tops. 
Lettuce    (including  romaine). 
31  ilk  weed. 
Sorrel. 

Cress    and    peppergrass, 
Oreen   peppers. 
Capers. 


Mint. 

Parsley. 

Endive. 

Chicory. 

Okra. 

Celery. 

Artichokes. 

Eggplant. 

Tomatoes. 

Cucumbers. 

Asparagus. 

Rhubarb    ( pieplant ) . 

Pumpkins. 

Squash. 

Onions. 

Garlic. 

Leeks. 

Shallots. 

Vegetable  marrow. 

Cranberries. 


VEGETABLE  FOODS  207 

Fruits 

Composition. —  The  varieties  of  fruits  consumed  in  all  countries 
are  innumerable,  and  their  uses  are  various.  Sweet  fruits  no  doubt 
largely  composed  the  diet  of  primordial  man,  as  they  do  of  every 
savage  tribe  to-day  living  outside  of  the  Arctic  Zone.  According  to 
C.  F.  Langworthy  fruits  compose  5.6  per  cent  of  the  total  American 
diet  and  4.9  per  cent  of  the  total  carbohydrate  diet. 

Speaking  generally,  fruits  are  composed  largely  of  water  with 
starches,  sugars,  pectin,  cellulose,  organic  acids,  essential  oils  and 
ethers.  To  the  two  latter  is  mainly  due  their  aroma  and  flavor  which 
is  also  dependent  upon  varying  proportions  of  sugars  and  acids. 

Fruit  sugars  are  sucrose  and  invert  sugar  (containing  dextrose  and 
levulose  in  equal  proportion). 

Pectin  is  a  soluble  carbohydrate  substance  found  in  ripe,  pulpy 
fruits.  It  enables  fruit  to  gelatinize  when  boiled  with  an  equal 
quantity  of  sugar.  Pectose  and  pectase  are  substances  present  in 
unripe  fruit.  The  latter  acts  upon  the  former  as  the  fruit  ripens, 
forming  pectin.  If  a  fruit  juice  ferments  or  is  cooked  too  long, 
pectin  loses  its  gelatinizing  power. 

The  organic  acids  exist  mainly  in  union  with  alkalies,  forming 
compounds  which  are  readily  split  up  in  the  system,  leaving  the  al- 
kalies free  to  combine  as  carbonates  or  phosphates. 

The  most  important  acids  are  citric,  malic,  and  tartaric,  which 
exist  in  various  quantities  and  combinations.  Citric  acid  predomi- 
nates in  lemons,  limes,  and  oranges;  tartaric  acid  in  grapes;  malic 
acid  in  apples,  pears,  peaches,  apricots,  gooseberries,  and  currants. 
Among  the  least  acid  of  the  common  fruits  are  peaches,  sweet  pears, 
sweet  apples,  bananas,  and  prunes;  moderately  acid  are  strawberries. 
The  most  acid  of  all  are  currants  and  lemons,  but  acid  fruits  may  also 
have  a  large  percentage  of  sugar.  Thus  currants  contain  four  or 
five  times  as  much  sugar  as  peaches,  which  contain  less  free  acid  and 
pectin. 

Fruits  contain  a  smaller  proportion  of  earthy  salts  than  other 
foods. 

Certain  fruits  also  hold  a  little  protein,  chiefly  as  albumins,  but, 
as  a  rule,  the  starches  and  sugars  predominate,  and  the  nutritive 
value  of  any  fruit  depends  upon  them.  Most  fruits  contain  too 
much  water  to  constitute  an  economic  diet  if  eaten  alone.  Some 
also  contain  a  small  quantity  of  fat  and  waxy  matter,  and  most  have 
more  or  less  pigment. 

Many  fruits  are  only  partially  edible  owing  to  the  fact  that  they 


208 


FOODS  AND  FOOD  PREPARATIONS 


are  composed  of  a  pulp  contained  within  an  indigestible  structure  of 
cellulose  or  woody  fiber. 

Fruits  are  commonly  classified  into  stone-bearing  fruits,  pomes, 
berries,  capsules,  and  pepos.  Some,  such  as  the  date,  the  plantain 
and  its  variety,  the  banana,  afford  sufficient  nutriment  amply  to  sup- 
port life  for  a  long  time;  others,  like  the  apple,  are  wholesome,  but 
slightly  nutritious;  while  others  again  are  of  little  use  for  nutritive 
purposes,  and  are  mainly  serviceable  for  their  agreeable  flavor  to 
furnish  variety  in  the  diet. 


Composition  of  Fruits,  Yearbook  of  Dept.  of  Agriculture,  1905. 
Langworthy). 


(C.  J. 


Kind  of  Fruit. 

Water. 

Pro- 
tein. 

Ether 
ex- 
tract. 

Carbohydrates. 

Ash. 

Fuel 
value 
per 
pound. 

Nitro- 
gen- 
tree  ex- 
tract. 

Crude 
fiber. 

FRESH   FRUITS. 
Apples     

Per  ct. 
84.6 
85.0 
81.1 
75.3 
86.3 
79.2 
80.9 
88.9 
85.0 
79.1 
85.6 
77.4 
82.9 
81.9 
89.3 
87.4 
89.5 
82.9 
67.0 
86.9 
89.4 
80.9 
80.2 
89.3 
78.4 
76.8 
79.6 
85.8 
94.4 
90.4 
92.4 

Per  ct. 
0.4 
1.1 
1.0 
1.3 
1.3 
1.4 
1.0 
.4 
1.5 
1.5 
1.0 
1.3 
1.3 
.6 
1.0 
.6 
.6 
.6 
2.5 
.8 
.7 
1.0 
1.4 
.4 
1.0 
1.5 
.9 
1.0 
.6 
1.0 
.4 

Per  ct. 
0.5 

Per  ct. 
13.0 
13 
6 

21.0 
8.4 
11.7 
16.5 
8.4 
12 
18 
13 
14.9 
8.0 
16 
7.4 
9.9 
7.2 
15 
5.7 
11 
5.8 
15.7 
15.1 
9.3 
20 
16.8 
18 
9.7 
2.5 
6.0 
6 

Per  ct. 

1.2 

4 
.8 
1.0 
2.5 
3.7 
.2 
1.5 
.8 
.8 
1 
4.3 
6.6 
6 
1.1 
1.2 
2.1 
9 
3.3 
6 
3.6 
1.5 
2.1 
.4 
1 
2.7 
.9 
2.9 
1.1 
1.4 
.7 

Per  ct. 
0.3 
.5 
.9 
.8 
.5 
2.7 
.6 
.2 
.7 
.6 
.3 
.5 
.5 
.3 
.5 
.5 
.6 
.6 
4.4 
.5 
.4 
.4 
.6 
.3 
.5 
.6 
.6 
.6 
.7 
.6 
.3 

Calories. 
290 
270 
512 
460 
270 
375 
365 
215 
265 
380 
255 
450 
315 
345 
205 
220 
185 
305 
407 
240 
190 
163 
174 
200 
395 
461 
370 
255 
105 
180 
140 

Apricots                         

Avocado     

10.2 
.6 
1.0 
1.3 

.8 
.6 

Bananas                       

Blackberries        

Cactus    fruit    

Cherries     .  .            .        

Cranberries               .          .... 

Currants                .            .... 

Figs    . 

Gooseberries    

Grapes  

1.6 

.7 
.6 
.7 
.4 

Guava    

Huckleberries          

Lemons    

Mango    

Muskmelons    

Nectarines     .... 

Olives     

17.1 
.2 
.1 
.5 
.6 
.3 

Oranges   

Peaches      

Pears      

Persimmons    (Japanese)    .... 
Pineapples    

Plums    

Pomegranates     

1.6 

Prunes   

Raspberries    (red)     

Rhubarb  stalks    

.7 
.6 
.2 

Strawberries     

^  atoi'melons             

In  dried  fruits  the  sugar  content  is  very  high,  as  follows :  raisins 
61  per  cent,  Zante  currants  54  per  cent,  dates  66  per  cent,  and 
prunes  32  per  cent. 


VEGETABLE  FOODS 


209 


Fruits  Arranged  According  to  the  Proportions  between  Acid,  Suga/r,  Pectin, 
Gum,  etc.     (Average)     (Fresenius). 


Fruits. 

Acid. 

Sugar 

Pectin,  gum,  etc. 

1 

1.6 

3.1 

Apricots     

1 

1.7 

6.4 

Peaches       

1 

2.3 

11.9 

Raspberries     

1 

2.7 

1.0 

Currants    

1 

3.0 

0.1 

Blackberries    

1 

3.7 

1.2 

Whortleberries    

1 

4.3 

0.4 

Strawberries    

1 

4.4 

0.1 

Gooseberries    .  .,  

1 

4.9 

0.8 

Prunes    

1 

7.0 

4.4 

Apples    . 

1 

11.2 

5.6 

Sweet  cherries    

1 

17.3 

2.8 

Grapes    

1 

202 

2.0 

TJses  and  Properties. —  The  uses  of  the  different  fruits  may  be  sum- 
marized as  follows: 

1.  To  furnish  nutriment.  2.  To  convey  water  to  the  system  and 
relieve  thirst.  3.  To  introduce  various  salts  and  organic  acids  which 
improve  the  quality  of  the  blood  and  react  favorably  upon  the  se- 
cretions. 4.  As  antiscorbutics.  5.  As  diuretics,  and  to  lessen  the 
acidity  of  the  urine.  6.  As  laxatives  and  cathartics.  7.  To  stim- 
ulate the  appetite,  improve  digestion,  and  give  variety  in  the  diet. 
8.  As  special  "  cures  "  for  certain  diseases,  like  the  grape  cure,  al- 
though their  specific  action  is  very  doubtful. 

In  a  study  of  the  diet  of  women  students  at  Lake  Erie  College  in 
Ohio,  made  in  1900  by  Isabel  Bevier  and  Elizabeth  C.  Sprague,  it 
was  found  that  an  increase  in  fresh  fruit  consumption,  especially  at 
breakfast,  showed  that  more  breakfast  was  eaten  and  it  materially 
lessened  the  craving  for  sweets. 

Fruits  which  afford  the  most  nutriment  are  the  banana,  date,  fig, 
prune,  and  grape.  This  is  due  to  the  large  proportion  of  sugar  which 
they  contain.  Those  which  contain  the  most  water  are  muskmelons, 
watermelons,  oranges,  lemons,  limes,  shaddocks,  and  grapes. 

The  antiscorbutic  value  of  fruits  is  illustrated  particularly  by  cer- 
tain varieties  which  furnish  abundant  potash  salts,  as  well  as  lime 
and  magnesia.  Among  these  are  to  be  mentioned  apples,  lemons, 
limes,  and  oranges. 

The  diuretic  influence  of  fruits  is  in  part  due  to  their  water,  but 
chiefly  to  their  organic  acids  and  salts,  which  stimulate  the  circula- 
tion and  probably  also  the  activity  of  the  renal  epithelium. 

Fruit-eating  lessens  the  acidity  of  the  urine  or  even  makes  it  alka- 


210         FOODS  AND  FOOD  PREPARATIONS 

line  owing  to  decomposition  of  various  alkaline  salts  in  the  blood  or 
tissues,  which  are  reformed  into  alkaline  carbonate  and,  as  such,  are 
excreted.  For  this  reason  fruit  is  sometimes  beneficial  in  lithaemia 
and  allied  conditions  to  prevent  accumulation  of  acid  urates. 

The  laxative  action  of  fruits  is  partially  derived  from  indigestible 
substances  as  cellulose,  seeds,  etc.,  and  also,  no  doubt,  from  the  special 
influence  of  their  organic  ingredients. 

The  best  fruits  to  offset  constipation  are  fresh  apples,  figs,  oranges, 
grape-fruit,  prunes,  and  peaches.  Dyspeptics  should  avoid  eating 
all  hard  skins,  seeds,  or  coarse-fibered  fruits. 

A  study  of  the  dietary  of  six  exclusive  fruitarians  (two  women 
and  four  children)  recently  was  made  by  Prof.  M.  E.  Jaffa  at  the 
California  Agricultural  Experiment  Station.  They  were  all  under- 
sized and  underfed,  and  the  following  was  an  average  daily  ration: 
475  gm.  apples,  110  gm.  bananas,  850  gm.  oranges,  5  gm.  dates,  2 
gm.  honey,  10  gm.  olive  oil,  55  gm.  almonds,  70  gm.  pine  nuts,  and 
50  gm.  walnuts.  A  fruit  diet  leaves  very  small  fecal  residue. 

Fruit  Eipening. —  As  fruit  ripens  it  absorbs  more  and  more 
oxygen,  and  the  tannin  and  vegetable  acids  which  it  originally  con- 
tained are  altered,  so  that  it  becomes  less  astringent  and  acid.  The 
starch  is  more  or  less  completely  turned  into  levulose  or  glucose, 
and  soluble  pectin  is  formed.  The  aroma  and  taste  of  ripe  fruits 
depend  upon  the  relative  quantity  of  these  different  substances,  to- 
gether with  various  volatile  ethers  and  oils.  The  sour  fruits  have 
either  more  acid  or  less  sugar,  and  in  the  sweet  fruits  there  is  a 
preponderance  of  sugar  which  masks  the  acid  taste.  The  more 
luscious  the  fruit,  the  more  soluble  sugars  and  special  flavoring 
substance  does  it  contain. 

Overripe  fruit  decays  through  action  of  molds  and  rots  which 
thrive  on  the  fruit  sugars  and  proteids  and  develop  new  gases,  odors 
and  flavors.  The  color  of  green  or  unripe  fruits  is  due  to  chlorophyll, 
and  a  yellow  color  is  due  to  xanthin. 

Fruit  Poisoning. —  While  fruits  eaten  daily  and  in  proper  modera- 
tion are  very  wholesome,  if  they  are  eaten  too  freely,  or  if  they  are 
either  insufficiently  ripe  or  overripe,  soft,  and  decomposing,  they 
undergo  malfermentation  in  the  alimentary  canal,  and  are  almost 
certain  to  cause  diarrhoea  with  colicky  pains,  cramps,  and  sometimes 
nausea  and  vomiting.  Severe  attacks  of  gastritis  may,  especially 
in  children,  be  produced  by  indulgence  in  unripe  apples,  pears,  cher- 
ries, berries,  etc.,  and  fatal  choleraic  diarrhoea  has  been  occasioned 
by  the  indiscriminate  consumption  of  fruits  which  have  strongly 
laxative  action.  After  such  fruit  poisoning,  emesis  should  be  ex- 


VEGETABLE   FOODS  211 

cited  if  the  patient  is  seen  in  time,  and  otherwise,  if  free  purga- 
tion has  not  occurred,  it  is  advisable  to  give  a  dose  of  castor  oil  or 
other  cathartic,  to  remove  the  irritating  substances  as  soon  as  pos- 
sible from  the  'alimentary  canal.  Certain  tropical  fruits  possess  spe- 
cific poisonous  properties. 

When  to  Eat  Fruit. —  Cooked  fruits  may  be  eaten  with  any  meal, 
but  usually  when  fruit  is  eaten  for  special  dietetic  purposes  its  effect 
is  more  pronounced  if  taken  alone,  either  at  the  commencement  of 
•meals,  or,  better,  between  them.  One  often  observes  patients  who 
can  obtain  no  laxative  effect  from  apples,  oranges  or  other  fruit 
eaten  as  dessert,  but  which  taken  at  night  into  an  empty  stomach 
or  an  hour  before  breakfast,  with  a  glass  or  two  of  cold  water,  has 
a  very  pronounced  favorable  influence  upon  the  bowels. 

The  poorest  time  for  eating  fruit  is  at  the  conclusion  of  a  very, 
hearty  dinner  at  which  considerable  variety  of  food  has  already  been 
consumed.  All  fruits,  such  as  berries,  the  seeds  of  which  are  eaten, 
are  much  less  liable  to  produce  intestinal  irritation  if  taken  with 
bread  or  other  bulky  starchy  food.  Eaw  fruit  unless  eaten  at  once 
after  picking  should  be  well  washed. 

Dried  fruits  are  eaten  less  abundantly  than  fresh  fruits.  Some 
of  the  dried  fruits  are  poorly  digestible;  such  are  currants  and 
citrons.  Others,  like  figs  or  prunes,  are  wholesome,  and  raisins, 
sultanas,  dates,  etc.,  contain  considerable  nourishment.  All  these 
dried  fruits  are  preserved  in  their  own  sugar  (glucose),  which  forms 
a  sticky,  gummy,  non-crystallized  mass.  Dried  apples,  peaches, 
prunelles,  etc.,  are  preserved  simply  by  the  evaporation  of  the  excess 
of  water  which  they  contain. 

Dried  "  currants  "  are  the  berries  of  a  vine  cultivated  in  the  Ionian 
Islands.  The  word  currant  is  a  corruption  of  Corinth. 

When  dried  fruits,  such  as  figs  or  dates,  have  become  too  hard 
they  may  be  softened  and  made  more  palatable  by  pouring  boiling 
water  over  them  and  allowing  them  to  soak  a  few  hours,  or  the 
fruit  may  be  put  into  milk  and  brought  to  the  boiling  point  over 
the  fire.  This  method  will  soften  them  in  a  quarter  of  an  hour. 

As  Langworthy  says,  fresh  fruits  are  dilute  food  comparable  to 
vegetables,  but  preserved  and  dried  fruits  compare  with  cereals  in 
food  value. 

Cooked  fruits  (or  "  compote ")  are  used  to  a  greater  extent  in 
Germany  and  France  than  in  the  United  States,  where  a  relatively 
large  proportion  of  fruit  is  eaten  raw.  Cooking  sterilizes  fruit,  and 
renders  contaminating  dirt  innocuous,  but  boiling  removes  4  to 
7  per  cent  of  the  nutritive  value. 


212          FOODS  AND  FOOD  PREPARATIONS 

Fruit  syrups  are  made  with  about  half  as  much  sugar  as  fruit 
juice. 

Fruit  Soups. —  In  Germany  fruit  soups  are  more  in  vogue  for 
general  use  than  in  this  country,  and  they  often  are  prescribed  in 
fevers  when  diarrhoea  does  not  exist.  Uffelmann  directs  that  for 
making  a  fruit  soup  one  part  of  fruit  to  four  or  five  of  water  may  be 
used,  and  Bauer  recommends  soups  "  made  by  boiling  fresh  or  dried 
fruits  with  water,  with  or  without  the  addition  of  sugar,  lemon  peel, 
etc.,  and  freed  from  the  solid  residue  by  pressure." 

Digestibility. —  Among  the  commoner  fruits  of  easy  digestion  are 
grapes,  oranges,  grape-fruit,  lemons,  cooked  apples,  figs,  peaches, 
cantaloupes,  nectarines,  blackberries,  strawberries,  and  raspberries. 

Somewhat  less  digestible  are  watermelons,  prunes,  raw  apples, 
pears,  apricots,  bananas,  fresh  currants,  pineapples  (except  the  plain 
juice),  quinces. 

Naturally  the  digestibility  depends  upon  ripeness  and  freshness 
of  the  fruit  as  well  as  personal  idiosyncrasy,  and  any  classification 
can  only  be  approximate. 

Fruits  Most  Useful  for  Invalids. —  The  most  useful  fruits  for  the 
sick  are  lemons,  oranges,  baked  apples,  stewed  prunes,  grapes, 
banana  meal  (not  the  fruit  pulp)  and  pineapple  juice. 

Varieties  of  Fruits. —  Lemons,  limes,  and  shaddocks  may  be  con- 
sidered together  as  possessing  the  same  general  properties.  Owing 
to  the  potash  and  other  salts  and  abundant  vegetable  acids  which 
they  contain,  they  are  the  most  serviceable  of  the  antiscorbutic  fruits, 
and  also  afford  an  agreeable  acid  and  pungent  flavor  to  other  articles 
of  diet.  For  many  persons  the  addition  of  a  little  lemon  juice  to 
some  foods,  such  as  cooked  cereals  and  porridge  or  broiled  fish, 
renders  them  more  immediately  digestible,  and  it  may  be  regarded 
as  having  almost  a  specific  action  promoting  gastric  digestion,  al- 
though it  is  difficult  to  say  in  just  what  manner  this  comes  about. 

Lemon  juice  is  a  well-known  mild  remedy  for  seasickness,  and 
holding  a  thin  slice  of  freshly  cut  lemon  in  the  mouth  often  removes 
the  disagreeable  taste  from  a  coated  tongue,  cleanses  the  mouth,  and 
may  counteract  nausea.  Sour  lemonade  taken  in  moderation  and 
made  quite  strong  by  squeezing  the  juice  of  one  or  two  lemons 
in  a  small  tumblerful  of  water,  with  the  addition  of  only  one  or  two 
lumps  of  su^ar,  is  a  cooling  and  refreshing  drink  in  fevers,  and  does 
more  to  diminish  the  craving  of  thirst  than  almost  any  other  form 
of  beverage.  For  those  who  fancy  effervescing  drinks,  the  lemonade 
may  be  improved  by  using  one  of  the  aerated  waters  —  such  as  Apol- 
linaris.  Vichy,  or  carbonic-acid  water  —  instead  of  plain  water,  or 


VEGETABLE  FOODS  213 

effervescence  may  be  produced  by  the  addition  of  ten  grains  of 
sodium  bicarbonate. 

Pure  lemon  juice  poured  into  the  nose  will  often  control  epistaxis. 
Fresh  lemon  juice  has  a  popular  reputation  for  warding  off  rheu- 
matism, but  is  has  been  shown  to  have  very  little  influence  over  nitro- 
gen elimination,  although  it  increases  the  phosphates  of  the  urine. 

Limes. —  The  lime  is  a  thin-skinned  acid  fruit,  but  there  is  also  a 
sweet  variety.  Although  less  extensively  eaten  throughout  this  coun- 
try than  the  lemon,  which  it  resembles  in  effect,  it  is  equally 
serviceable,  and  ten  thousand  gallons  of  condensed  lime  juice  are 
imported  annually  into  this  country  from  Jamaica.  To  make  this 
juice  the  fresh  limes  are  pressed  by  machinery,  and  the  seeds  and 
pulp  removed  by  straining  and  filtering.  The  juice  is  then  boiled 
down  to  a  high  degree  of  concentration.  It  is  carried  on  sailing 
vessels  to  prevent  scurvy,  and  used  in  almshouses  and  prisons,  where 
the  diet  is  monotonous. 

The  shaddock,  pomelo,  or  Citrus  pomelanus,  is  a  very  large,  globular 
pulpy  fruit,  which  may  attain  to  a  weight  of  fifteen  pounds.  The 
rind  is  thick  and  acid,  and  the  very  juicy  pulp  is  bitter.  The  fruit 
keeps  fresh  a  long  time.  A  smaller  variety,  known  as  the  grape- 
fruit, has  come  into  general  use  of  late,  although  still  a  relatively 
expensive  fruit.  It  grows  in  pendant  clusters.  Many  persons  find 
that  half  a  grape-fruit  taken  at  the  commencement  of  breakfast  has 
both  a  laxative  and  diuretic  action,  and  it  is  always  cooling  and 
agreeable  to  those  who  do  not  dislike  a  bitter  taste.  The  objection 
to  its  use  is  that  it  requires  a  large  quantity  of  sugar  to  make  it 
really  palatable  and  diminish  its  astringency.  This  is  disadvan- 
tageous in  cases  of  flatulent  dyspepsia,  but  for  invalids  who  are 
convalescing  from  prolonged  fevers,  suppurating  disease,  etc.,  an  ex- 
cellent tonic  may  be  given  by  cutting  a  grape-fruit  in  two  and 
pouring  a  dessertspoonful  of  good  rum  or  of  curacoa  into  the 
fruit,  with  addition  of  a  little  sugar.  The  bitterness  is  entirely 
disguised  and  the  combination  is  agreeable  and  appetizing.  Modern 
cultivation  methods  are  making  this  fruit  less  acid  than  formerly. 

Oranges. —  Oranges  are  an  exceedingly  useful  article  of  invalid 
diet.  The  juice  of  ripe  oranges  allays  thirst,  and  is  well  borne  in 
cases  where  there  is  considerable  gas-trie  irritation  and  tendency  to 
vomiting.  It  is  only  in  the  gravest  forms  of  gastric  disorder  that 
orange  juice  disagrees,  and  there  is  no  fruit  which  is  so  generally 
available  in  the  sick-room,  for  it  is  agreeable  to  almost  every  one, 
and  is  refreshing  in  fevers.  I  often  give  it  in  typhoid  fever.  Orange 
juice  is  laxative,  particularly  for  infants,  and  is  the  best  remedy 


214 


FOODS  AND  FOOD  PREPARATIONS 


for  infantile  scurvy.  It  may  be  given  undiluted  or  made  into 
orangeade  with  one  of  the  effervescing  waters.  In  renal  and  other 
diseases  in  which  it  is  desirable  for  the  patient  to  drink  large  quan- 
tities of  fluid  for  its  diluent  and  diuretic  effect,  the  addition  of 
orange  juice  TO  beverages  will  encourage  their  consumption.  An  ex- 
cellent remedy  for  constipation  is  the  juice  of  three  oranges  squeezed 
into  a  tumblerful  of  Vichy,  and  drunk  on  rising  and  again  at  bed- 
time. 

Orange  marmalade  is  a  wholesome  relish,  having  an  appetizing, 
bitter  flavor. 

Orange  water  ice,  as  well  as  lemon  ice,  well  frozen,  if  not  made 
too  sweet,  may  be  allowed  in  the  milder  forms  of  fever,  inflammations 


PERCENTAGE  COMP&- 
S/r/O/V  OfEOfBLE 


FIG.  38. —  COMPOSITION  OF  APPLE.. 
(Yearbook,  U.  S.  Dept.  of  Agri.,  1905.     C.  F.  Langworthy.) 

of  the  throat,  etc.,  especially  in  children.  It  is  refreshing,  and 
cooling,  and  is  less  likely  to  disagree  than  the  richer  ice'  cream. 

Apples,  when  ripe  and  .  properly  selected,  are  very  whole- 
some. They  contain  abundant  potassium  and  sodium  salts,  as  well 
as  those  of  lime,  magnesium,  and  a  trace  of  iron.  Their  nutritive 
value  is  not  high,  depending  mainly  upon  a  little  sugar,  for.  they 
are  largely  composed  of  water,  having  over  83.5  per  cent.  In  dried 
apples  the  percentage  of  water  is  reduced  to  one-third,  while  "that  of 
sugar  is  proportionately  increased. 

Apples  contain  free  organic  acids  (malic  and  gallic)  as  well  as 
salts,  such  as  malates,  citrates,  and  tartrates.  They  also  contain  lime, 
phosphates,  plant  albumin,  gum,  and  chlorophyll.  They  are  good 
antiscorbutic  remedies,  and  are  laxative,  especially,  when  taken  into 
an  empty  stomach.  There  are  many  dyspeptics  who  thrive  upon 
apples,  oven  if  eaten  raw,  and  who  can  regulate  the  action  of  the 
bowels  with  them  effectually.  They  should  be  given  to  most  in- 


VEGETABLE   FOODS  215 

valicls  only  when  cooked.  They  are  most  digestible  when  baked  and 
eaten  with  creamy  or  they  may  be  beaten  with  white  of  egg  to  add 
to  their  nutritive  power.  They  are  palatable  and  digestible  for  con- 
valescents if  stewed  as  apple  sauce,  when  there  is  no  objection  to 
the  addition  of  the  greater  quantity  of  sugar  which :  is  required  in. 
this  method  of  cooking.  They  should  be  ayoided  in  cases  of 
diarrhoea,  gastrointestinal  irritation,  and  diabetes. 

Crab-apples  are  used  only  to  make  a  jelly  which  is  wholesome, 
but  not  suitable  for  invalids,  being  both  too  acid  and  sweet. 

Pears  are  similar  to  apples  in  their  effect,  but  are  less  laxative. 
If  fully  ripe  and  soft  they  are  even  more  digestible  raw  than  apples. 
They  have  the  advantage  of  keeping  their  flavor  when  well  pre- 
served in  sirups,  but  they  possess  no  special  food  value,  and  are 
mainly  used  for  their  choice-  flavor,  aroma,  and  appearance,  which 
stimulate  the  appetite. 

Guava  is  a  fruit  of  which  there  are  many  varieties,  both  whole- 
some and  nutritious.  In  the  tropics  it  is  used  almost  as  extensively 
as  apples  in  temperate  regions.  In  the  Southern  United  States  it  is 
also  cultivated  and  is  eaten  chiefly  in  the  form  of  a  jelly. 

Quinces  are  indigestible  unless  very  thoroughly  cooked,  or  made 
into  jelly  or  marmalade. 

Peaches,  nectarines,  ami  apricots  are  of  comparatively  little  nutrient 
value,  but  their  flavor  and  appearance  make  them  tempting  articles 
for  the  table.-  They  do  not  contain  as  much  sugar  as  apples  and 
other  fruits.  When  thoroughly  ripe  they  are  wholesome  if  not 
'eaten  in  excess.  They  agree  well  with  some  gouty  persons,  and  are 
even  allowed  to  diabetics  in  cases  of  moderate  severity.  Peach  and 
apricot  juices  are  laxative. 

Pineapples  (Ananassa  satiya] ,  as  usually  obtained  in  this  country, 
have  been  picked  green  in  Cuba^  and  if  eaten  raw  with  the  fibrous 
structure  are  indigestible.  Their  ripe  juice  however,  is  very  whole- 
some, and  they  contain  a  ferment  capable  of  digesting  proteid  ma- 
terial, which  is  used  to  some  extent  in  the  preparation  of  predigested 
invalid  foods,  such  as  Mosquera's  beef  meal  (p.  132).  Prof.  E.  H. 
Chittenden  has  isolated  this  ferment,  which  has  a  rapid  softening, 
disintegrating,  and  digesting  effect  upon  such  proteids  as  blood  fibrin 
and  muscle  tissue.  It  is  an  acid  fluid  which  acts  best  in  a  neutral 
medium,  but,  like  trypsin,  it  also  digests  in  both  acid  and  alkaline 
solution.  Three  ounces  of  the  juice  will  dissolve  ten  to  fifteen  grains 
of  dried  albumin  in  four  hours.  He  also  found  a  milk-curdling 
ferment  in  the  juice. 

One  ripe  pineapple  yields  about  a  pint  of  juice,  which  when  sweet- 


216          FOODS  AND  FOOD  PREPARATIONS 

ened  and  added  to  an  effervescing  water,  makes  a  wholesome  laxative 
and  delicious  beverage. 

Tamarinds  are  cooling  and  laxative.  When  added  to  milk  they 
cause  curdling,  and  form  a  whey  which  may  be  used  as  a  beverage  in 
fevers  when  constipation  is  to  be  overcome.  (See  Receipts  for  In- 
valid Food.) 

The  mango  is  a  sweet  and  somewhat  acid  fruit,  with  moderately 
laxative  action. 

The  pomegranate  is  a  pulpy  fruit,  wholesome  when  fresh,  but  it  is 
expensive  and  little  used  in  this  country.  It  has  a  thick,  tough 
rind,  which  is  astringent,  with  a  bitter-sweetish  taste.  A  taeniacide 
for  the  tapeworm  is  made  from  an  infusion  of  the  rind,  but  it  is  so 
nauseous  and  disgusting  to  the  taste  that  patients  can  seldom  retain 
it  unless  it  is  put  into  the  stomach  through  an  oesophageal  tube. 

Bananas. —  The  banana  is  really  a  variety  of  the  plantain,  or  Plan- 
tago  musa,  but  the  fruit  is  not  so  large  or  so  hard  as  that  commonly 
called  plantain,  and  the  flavor  is  far  more  delicate.  The  botanical 
name  of  the  banana,  Musa  sapientum,  was  given  because  it  constituted 
the  principal  food  of  the  Brahmin  caste  of  India.  There  are  many 
score  of  varieties  of  the  banana,  ranging  from  the  most  delicate 
examples  of  the  Musa  sapientum  family  to  the  heaviest  of  the  plan- 
tains, and  they  vary  in  digestibility  as  they  do  in  flavor.  Casati 
("Equatorial  Province/'  1891)  names  some  fourteen  varieties,  hav- 
ing different  characteristics  and  existing  in  the  Equatorial  Province 
of  Africa  alone.  He  noted  that,  curiously,  only  the  women  and 
children  ate  the  natural  fruit,  the  warriors  feeding  on  the  fruits  dried 
and  prepared  in  oil  —  probably  from  an  intuition  that  they  were 
more  highly  nourished  by  the  concentrated  food. 

In  the  West  Indies,  in  the  islands  of  the  Pacific,  along  the  Congo, 
and  throughout  Central  Africa  many  natives  eat  bananas  as  their 
staple  article  of  food,  and  maintain  good  physical  development.  The 
fact  that  a  diet  consisting  solely  of  this  fruit  will  sustain  life  for 
long  periods  is  owing  to  the  relatively  high  percentage  of  nitrogen 
which  it  contains,  amounting  to  nearly  five  parts  per  hundred  of  the 
entire  fruit,  or  one-fifth  of  the  total  solids  (Corenwinder).  Grown 
on  a  given  acreage,  bananas  will  support  a  larger  number  of  persons 
than  wheat. 

The  banana  has  of  late  years  assumed  a  very  important  position 
among  fruits  sold  in  this  country.  Improvements  in  cultivation  and 
means  of  transportation,  and  the  length  of  time  through  which  the 
fruit  will  keep  without  spoiling,  are  accountable  for  this,  and  up- 
wards of  one  hundred  thousand  bunches  of  bananas  are  sold  per 


VEGETABLE   FOODS 


217 


month  for  distribution  in  New  York  city  and  vicinity  alone.  It 
ranks  equally  with  the  orange  in  extent  of  consumption,  and  during 
the  winter  months  it  is  often  the  only  fresh. fruit  which  is  universally 
obtainable  in  remote  country  districts,  while  its  cheapness  places  it 
within  reach  of  almost  every  one. 

In  British  Guiana  the  banana  is  employed  especially  as  a  nourish- 
ing food  for  young  children  and  invalids. 

Many  persons  find  that  they  cannot  easily  digest  bananas  as  ob- 
tainable in  this  country;  but  this  no  doubt  depends  upon  the  fact 
that  the  fruit  shipped  to  the  United  States  is  picked  very  green,  and 


REFUSE   4 


ED/3LE  PORT/ON 
65J& 


FIG.  39. —  COMPOSITION  OF  BANANA. 
(Yearbook,  U.  S.  Dept.  of  Agri.,  1905.     C.  F.  Langworthy.) 

is  often  immature  and  irregularly  ripened  when  eaten.  Imperfectly 
ripened  bananas  are  composed  chiefly  of  starch,  but,  as  the  natural 
ripening  proceeds,  the  saccharine  material  is  converted  into  a  muci- 
laginous substance,  which  in  turn  forms  dextrin  and  glucose.  The 
flour,  which  is  made  by  drying  carefully  selected  and  well-ripened 
bananas,  is,  however,  remarkably  easy  to  digest,  and  highly  nutritious. 
Surgeon  Parke  ("  My  Personal  Experience  in  Equatorial  Africa," 
p.  416),  in  an  instructive  and  interesting  account  of  his  experience 
with  the  sick  of  the  Emin  Pasha  Relief  Expedition,  refers  to  Mr. 
Stanley,  who  was  in  the  midst  of  a  severe  attack  of  acute  gastritis, 
as  follows :  "  He  eats  porridge  made  with  banana  flour  and  milk.  It 


218          FOODS  AND  FOOD  PREPARATIONS 

is  very  light  and  digestible,  and  has  more  flavor  than  arrowroot;  it 
is  also  very  nutritious.  We  whites  have  very  good  reason  to  know 
this  fact  now,  as  we  have  mostly  lived  on  banana  flour  for  the  past 
two  years/'  During  most  of  this  period,  it  should  be  observed,  the 
members  of  the  expedition  were  taking  very  long  marches  and  were 
suffering  from  frequent  attacks  of  malarial  fever,  which  were  a 
severe  test  of  the  nutritive  qualities  of  any  dietary. 

It  is  difficult  to  make  a  good  fruit  flour,  for  most  fruits,  when 
dried,  form  a  mucilaginous  mass  like  the  fig,  or  a  sticky  material  like 
the  raisin,  or  shrivel  to  a  stringy  substance  like  the  apple  and  the 
apricot.  But  the  banana  constitutes  an  important  exception,  and 
when  carefully  selected  and  thoroughly  dried  may  be  ground  into  a 
meal  or  even  into  a  flour,  making  as  fine  a  powder  as  arrowroot,  hav- 
ing a  white  or  pale  grayish  or  yellowish  color,  and  an  agreeable 
faintly  aromatic  odor  and  taste. 

This  meal  possesses  decided  intrinsic  advantages  as  an  invalid 
food.  I  have  tested  these  preparations,  both  experimentally  in  the 
laboratory  and  clinically,  and  found  that  an  unboiled,  saturated 
aqueous  solution  of  banana  flour  contains  a  very  large  percentage 
of  sugar  —  from  one-half  to  three-fourths  as  much  as  certain  of  the 
best  known  prepared  saccharine  foods  for  infants  to  which  sugar  had 
been  artificially  added.  The  finest  banana  flour,  called  "  bananose," 
at  the  end  of  one  and  a  half  hour  of  pancreatic  digestion  developed 
twice  as  much  sugar  as  the  same  quantity  of  oatmeal  or  farina, 
and  approximately  one  and  a  half  times  as  much  sugar  as  cornstarch. 
Saliva,  when  substituted  for  pancreatic  extract,  produces  a  similar 
effect. 

Banana  flour,  when  prepared  from  the  best  quality  of  bananas, 
is  made  into  a  thin  gruel  or  porridge  by  the  addition  of  either  water 
or  milk,  and  eaten  with  cream  it  constitutes  a  delicious  and  highly 
nutritious  article  of  diet  suitable  in  cases  of  gastric  irritability  and 
acute  gastritis,  etc.  It  is  particularly  serviceable  for  children  be- 
tween five  and  ten  years  of  age.  For  those  craving  an  acid  flavor, 
lemon  juice  with  powdered  sugar  upon  the  banana  porridge  is  found 
very  acceptable.  The  records  of  some  fifty  patients  in  the  New 
York  and  Presbyterian  Hospitals  to  whom  I  gave  gruel  or  porridge 
made  with  banana  flour  show  that  it  was  exceptionally  well  borne  by 
irritable  stomachs,  almost  never  vomited,  having  no  tendency  to  pro- 
duce acidity  from  flatulence,  nor  did  it  cause  diarrhoea  or  any  ap- 
parent laxative  effect.  It  proved  very  useful  in  cases  of  simple  gas- 
tritis and  acute  gastritis  complicating  chronic  indigestion  and  in  the 
early  convalescent  stage  of  typhoid  fever.  It  was  used  with  ad- 


VEGETABLE   FOODS  219 

vantage  during  the  fever  itself  whenever  a  change  from  an  exclusive 
milk  diet  seemed  indicated  either  by  the  patient's  dislike  for  milk  or 
by  its  causing  dyspepsia. 

The  taste  of  banana  flour  is  peculiar,  and  is  not  always  agreeable 
at  first;  but  it  may  be  so  modified  by  different  processes  of  cooking 
that  the  majority  of  patients  find  it  much  more  palatable  than  the 
conventional  arrowroot,  cornstarch,  or  farina.  It  is  a  decided  gain 
to  be  able  to  enlarge  the  list  of  starchy  foods  adapted  to  feeble 
digestions  by  a  fruit  flour  which  presents  the  following  advantages: 
An  agreeable  variety  of  taste;  a  high  percentage  of  nitrogen,  dex- 
trin, and  glucose;  ready  digestibility;  high  nutritive  value;  the  prop- 
erty of  keeping  indefinitely  in  a  concentrated  dry  state,  ready  for  im- 
mediate use. 

Grapes. —  Perfectly  ripe  and  seedless  grapes,  such  as  the  Black 
Hamburg  and  other  varieties,  have  long  been  recognized  as  an  ex- 
cellent food  for  invalids.  Grapes  contain  so  large  a  proportion  of 
water  that  they  possess  little  nutrient  property,  although  they  hold 
considerable  sugar,  but  the  salts  which  they  furnish  to  the  system 
are  useful.  These  are  the  sulphates,  phosphates,  and  chlorides  of 
sodium,  potassium,  calcium,  magnesium,  and  iron. 

The  average  percentage  composition  of  grapes  is  given  by 
Konig  as : 

Water  78.17 

Sugar    14.36 

Free  acid   0.79 

Nitrogeneous  material    0.59 

Extractives    1.96 

Stones  and  woody  fibre 3.60 

Ash   0.53 

The  habit  some  persons  have  of  swallowing  the  pulp  whole  with 
the  seeds,  however  small  the  latter  may  be,  cannot  be  condemned 
too  strongly.  The  seeds  under  no  circumstances  are  digested,  being 
too  hard  and  tough  to  be  affected  by  any  of  the  juices  of  the  di- 
gestive tract,  and  therefore  act  as  irritants  or  foreign  bodies.  It 
was  originally  believed  that  inflammation  of  the  appendix  vermiformis 
was  often  caused  by  the  entrance  of  one  or  two  sharp-pointed  grape 
seeds  into  this  small  division  of  the  alimentary  canal,  but  this  has 
been  proved  to  be  an  exceedingly  rare  occurrence.  The  seeds  eaten 
in  excess  are  liable  to  cause  diarrhoea,  enteritis,  or  intestinal  obstruc- 
tion. Swallowing  the  skins  of  grapes  is  equally  harmful. 

Grapes,  on  account  of  their  sugar,  should  be  excluded  in  cases  of 
diabetes  and  gout.  A  special  "  grape  cure  "  has  been  established  for 
some  diseases.  (See  Grape  Cure.)  IJnfermented  California  grape 


220          FOODS  AND  FOOD  PREPARATIONS 

juice  constitutes  an  agreeable,  wholesome,  and  slightly  laxative,  non- 
alcoholic beverage,  which  may  be  prescribed  during  mild  fevers  and  in 
convalescence.  Prof.  Albert  E.  Leeds  sent  me  the  analysis  of  a 
grape  food  which  he  says  "  is  entirely  different  from  the  grape  juice, 
inasmuch  as  it  contains,  both  in  amount  and  condition,  the  con- 
stituents of  the  grape  to  a  point  of  practical  completeness  to  which 
the  manufactured  juices  have  failed  to  attain.  I  have  verified  by 
most  exhaustive  tests'  the  absence  of  all  germs  of  fermentation,  and 
this  sirup  will  certainly  keep  indefinitely,  even  in  the  absence  of 
alcohol  or  antiseptic."  This  "liquid  grape  food"  contains  protein 
and  64  per  cent  of  grape  sugar,  with  no  alcohol  and  no  starch. 

Raisins,  prepared  by  sun-drying  from  certain  species  of  grapes 
which  are  particularly  rich  in  sugar,  form  a  useful  food,  chiefly  on 
account  of  the  agreeable  flavor  which  they  impart  to  more  insipid 
substances.  (See  also  Eaisin  Wine,  p.  284.) 

Raisins  are  usually  made  from  white  grapes,  but  they  turn  dark 
purple  or  brown  from  oxidation  of  the  tannic  acid  of  their  skins. 
Muscatel  raisins  are  dried  on  the  vine  by  incising  the  stems  to  cause 
withering  of  the  grapes. 

Raisins  cannot  be  eaten  very  abundantly  without  disordering  di- 
gestion unless  they  have  been  cooked.  Added  to  some  forms  of 
farinaceous  food  —  such  as  rice  pudding,  sweetened  breads,  buns, 
cakes,  pemmican,  and  the  like  —  they  increase  the  appetite.  If  given 
to  children,  as  they  too  often  are,  they  should  be  stoned  carefully 
beforehand,  and  the  tough  skins  should  not  be  swallowed.  The  latter 
contain  a  whitish  waxy  material  which  keeps  the  grapes  waterproof. 
Raisins  form  an  ingredient  of  pemmican  (p.  233). 

Plums. —  Plums  and  greengages  are  wholesome  fruits  when  they 
are  wholly  ripe;  but  they  remain  fresh  for  only  a  short  time,  and  are 
often  on  that  account  picked  and  sent  to  market  in  an  unripe  condi- 
tion, in  which  they  are  very  indigestible,  and  are  prone  to  excite 
diarrhoea  and  intestinal  colic. 

Prunes. —  Primes  or  dried  plums  are  obtainable  in  various  forms 
and  sold  in  large  masses  like  dates,  or  preserved  individually  in  jars, 
in  which  form  they  have  the  advantage  of  keeping  well  for  a  long 
period.  They  contain  a  large  percentage  of  sugar.  They  have  a  dis- 
tinctly laxative  effect,  eaten  raw,  or,  preferably,  stewed,  and  are 
very  wholesome  and  useful  in  cases  of  chronic  constipation.  They 
are  comparatively  inexpensive,  and  by  some  patients  may  be  taken 
two  or  three  times  a  day.  They  have  good  effect  in  regulating  the 
bowels  in  children,  and  three  or  four  prunes  given  once  or  twice  a 
day  hetwo?n  meals  will  sometimes  prove  quite  sufficient  for  this 


VEGETABLE  FOODS 


221 


purpose.  The  tough  skins  should  be  removed  before  serving  to  chil- 
dren and  invalids. 

Prunelles  are  sold  in  masses  dried  like  dates.  They  have  a  pleas- 
ant acid  flavor,  but  are  not  very  digestible. 

Olives  are  eaten  for  their  agreeable  flavor  and  nutrient  value, 
which  is  due  to  the  oil  they  contain.  (See  Olive  Oil.)  They  are 
much  eaten  as  a  relish,  either  plain  or  stuffed  with  peppers,  and 
are  used  for  garnishing  salads,  sauces,  etc.  About  seventy  varieties 
are  now  grown  in  California.  They  may  be  eaten  fresh  with  bread 
in  the  warm  countries  where  they  grow,  but  they  are  too  bitter  for 
most  palates,  and  are  usually  preserved  by  soaking  respectively  in 
(a)  strong  lye,  (&)  fresh  water,  and  (c)  salt  solution,  and  are  left 
in  the  latter  for  preservation.  The  lye  neutralizes  their  bitter  taste. 
In  Greece  small,  black,  dried  olives  are  much  eaten.  The  composi- 
tion of  the  ash  of  California  olives  presents,  among  other  ingredients, 
60  per  cent  of  potash,  16  per  cent  of  lime,  and  8.3  per  cent  of  phos- 
phoric acid. 

Composition  _of  Pickled  Ripe  and  Green  Olives. 
(C.  B.  Smith  and  F.    Langworthy). 


Water. 

Fats  (oil). 

Carbohy- 
drates. 

Protein, 
ash,  etc. 

Pickled 

ripe   olives    

Per  ct. 

65  08 

Per  ct. 

25  52 

Per  ct. 
3  75 

Per  ct. 
5  65 

Pickled 

green  olives   

78.41 

12.90 

1.78 

6.91 

Berries. —  The  strawberry,  on  account  of  its  exceptionally  agree- 
able flavor,  and  also  from  the  fact  that  it  is  one  of  the  first  fruits  of 
the  spring  season  in  the  eastern  part  of  this  country,  is  enjoyed  by 
almost  every  one.  There  are,  however,  a  few  persons  who  have  a 
striking  idiosyncrasy  against  it,  and  in  whom  urticaria  or  more  or 
less  violent  gastro-enteritis  with  sore  throat  is  promptly  developed 
by  taking  a  few  berries.  The  reason  for  this  is  not  fully  explained, 
for  analysis  of  the  strawberry  fails  to  show  any  product  which  is 
peculiar  to  itself.  There  must  consequently  be  some  combination  of 
organic  acids  or  other  materials  existing  in  this  berry  which  is  ex- 
ceptionally irritating  to  some  persons. 

The  strawberry  is  usually  a  very  wholesome  food.  It  contains 
abundant  salts  of  potash,  lime,  and  soda,  which  give  it  a  moderate 
diuretic  action;  it  is  also  slightly  laxative,  partly  from  the  seeds 
which  it  contains.  There  are  many  modes  of  eating,  cooking,  and 
preserving  the  strawberry  which  are  too  familiar  to  require  mention. 


FOODS   AND   FOOD   PREPARATIONS 

Some  persons  learn  that  eating  the  berry  with  pepper  or  lemon  juice 
enables  them  to  digest  it  better,  and  those  who  suffer  from  flatulent 
dyspepsia,  if  they  can  digest  the  berry  at  all,  do  well  to  take  it 
without,  sugar. 

Currants,  bilberries,  mulberries,  blueberries,  huckleberries  (whortle- 
berries), raspberries,  blackberries,  and  gooseberries  all  contain  con- 
siderable free  acid,  and  are  moderately  laxative,  partly  on  account 
of  their  seeds,  but  their  expressed  juices  sometimes  have  the  same 
effect.  Not  all  berries  are  laxative,  however.  Huckleberries  and 
blueberries  may  be  laxative  when  eaten  with  their  seeds  and  skins, 
but  Wmternitz  has  shown  that  a  decoction  made  from  these  berries 
is  a  good  astringent  for  use  in  chronic  diarrhoea.  Blackberries  have 
a  similar  action. 

The  expressed  juice  of  red  currants,  raspberries,  or  blackberries 
makes  a  cooling  and  refreshing  beverage  or  "shrub"  when  added  to 
some  effervescing  water,  such  as  Apollinaris  or  carbonic-acid  water, 
and  sometimes  may  be  used  in  fevers,  although  lemon  or  orange 
juice  is  usually  preferable. 

Currants  are  preserved  in  various  ways,  the  chief  one  being  in 
the  form  of  jelly.  Prepared  in  this  manner,  they  constitute  an  appe- 
tizing and  wholesome  flavoring  material,  which  may  be  taken  with 
meats  and  other  foods  to  excite  the  appetite  of  invalids  and  con- 
valescents whose  chief  difficulty  is  lack  of  desire  for  sufficient  food. 

Currants,  raspberries,  blackberries,  etc.,  are  frequently  made  into 
jams.  These,  on  account  of  the  large  quantity  of  sugar  which  is 
added  in  their  preparation,  are  quite  nutritious,  and  their  numerous 
seeds  have  a  laxative  action.  For  this  purpose  they  are  sometimes 
beneficially  given  to  older  children  to  be  eaten  with  bread  and  butter. 
They  aid  in  satisfying  the  natural  craving  of  children  for  sweets, 
and,  if  taken  in  moderation,  are  wholesome,  and  their  flavor  may 
encourage  the  eating  of  more  nutritious  but  less  agreeably  flavored 
food,  such  as  rice,  cornstarch,  or  farina. 

The  gooseberry  is  much  more  popular  in  England  than  in  the 
"United  States.  It  contains  citric  and  malic  acids  as  well  as  sugar. 
It  is  rendered  more  wholesome  by  cooking,  and  is  sometimes  made 
into  wine. 

The  elderberry  furnishes  an  astringent  wine,  which  is  also  somewhat 
diuretic  and  sudorific. 

In  general,  berries  having  tough  skins  like  the  blueberry  are  less 
digestible  than  those  without  skins  like  the  raspberry,  and  the  skins 
and  seeds  often  are  found  undigested  in  the  feces. 

Melons. —  Melons   are  of  little   service  for  nutrition,  but   are  so 


VEGETABLE  FOODS  223 

agreeable  to  the  palate  that  they  are  in  general  favor.  The  varieties 
commonly  obtainable  in  this  country  are  the  cantaloupe,  or  musk- 
melon,  and  watermelon,  and  of  these,  the  former  is  less  likely  to  pro- 
duce gastrointestinal  disorder  when  not  eaten  too  freely. 

These  fruits  contain  so  large  a  proportion  of  water  —  upward  of 
95  per  cent  —  that  they  do  not  quickly  satisfy  the  appetite ;  and  since 
in  hot  weather  they  are  cool  and  refreshing,  overindulgence  in  them 
is  a  common  fault,  and  most  of  the  ill  repute  of  watermelons  has 
arisen  in  this  way  rather  than  from  any  specific  injurious  effect  which 
they  produce.  If  eaten  with  other  food,  they  dilute  the  gastric  juice. 
Well-ripened  muskmelons  often  may  be  eaten  by  invalids  in  modera- 
tion to  promote  the  appetite,  served  at  the  commencement  of  a  meal, 
at  which  time  it  is  best  that  most  fruit  should  be  eaten  if  taken  with 
other  food. 

Citrons  are  most  indigestible. 


ED/BLE 'POR77ON 

/OO°/<3 


/oo.o<fi  row. 


FIG.  40. —  COMPOSITION  OF  DRIED  FIG. 
(Yearbook,  U.  S.  Dept.  of  Agri.,  1905.     C.  F.  Langworthy. ) 

Figs  and  Dates. —  Figs  and  dates  are  chiefly  eaten  in  the  United 
States  in  the  dry  form,  although  in  California  and  elsewhere  they 
may  be  obtained  fresh.  These  fruits  hold  large  quantities  of  sugar, 
especially  in  their  dry  state,  in  which  this  ingredient  is  not  only  con- 
centrated, but  changed  in  the  drying  process.  They  also  contain  a 
little  protein  material,  so  that  they  have  more  nutritive  value  than 
many  fruits;  in  fact,  in  some  Eastern  countries  they  constitute  a 
staple  article  of  diet,  as  illustrated  by  the  use  of  the  date  in  Arabia. 

Figs  have  a  decided  aperient  action,  which  is  chiefly,  but  not  solely, 
owing  to  their  seeds.  Three  or  four  dried  figs  taken  with  a  glassful 
of  water  at  night  before  retiring,  and  again  half  an  hour  before  break- 
fast, will  sometimes  cure  mild  constipation.  The  dried  figs,  like 
prunes,  may  be  stewed  if  preferred.  They  contain  a  large  percentage 
of  glucose.  The  best  figs,  called  Turkey  figs,  are  raised  in  Smyrna, 
and  when  dried  will  keep  for  a  long  time. 

The  prickly  pear  or  tuna  is  the  fruit  of  a  cactus  of  the  Opuntia 


224: 


FOODS   AND   FOOD   PREPARATIONS 


family.  It  is  called  also  Barbary  or  Indian  fig,  and  is  eaten  chiefly 
in  Mexico,  but  also  as  a  luxury  in  the  United  States.  The  fruit  is 
pear-shaped,  or  sometimes  round,  and  of  a  greenish  purple  color.  It 
is  covered  with  spines  and  groups  of  spicules,  hence  its  name.  The 
fruit  has  a  thin  skin  and  a  rind  about  one-third  inch  in  thickness  and 
contains  a  multitude  of  seeds,  with  about  10  per  cent  of  edible  solids, 
largely  sugars,  with  a  little  proteid,  acid  and  ash. 

Fungi 

There  are  many  species  of  fungi,  some  of  which  are  available  for 
food,  whereas  others  are  irritating,  and  still  others  produce  violent 
gastrointestinal  disorder,  and  by  their  absorption  give  rise  to  symp- 
toms of  collapse,  and  may  cause  death. 

Konig  gives  the  f ollowing  percentage  composition : 


Fresh 
mushroom. 

Fresh  truffle. 

Fresh  common 
morel. 

\Vater          >                         

91  11 

72  08 

90  00 

Non-nitrogenous  substances   .... 
Fat                                          

2.57 
0  13 

8.91 
0  62 

3.48 
0  24 

Grape  sugar    mannite   

1.05 

0  72 

Other  non-nitrogenous  substances 
Woody    fibre    

3.71 
0.67 

7.54 
7.92 

3.95 
0.67 

Ash    

0.76 

2.21 

0.94 

Edible  Fungi. —  Mushrooms. —  Mushrooms,  on  account  of  their 
nitrogenous  material,  are  of  some  slight  use  as  food;  but  if  eaten  in 
sufficient  quantity  to  yield  much  nutriment,  they  always  disagree. 
Bauer  says :  "  Judging  from  their  chemical  composition,  they  ought 
to  have  no  small  value  as  foods,  but  it  is  doubtful  how  far  they  are 
really  utilized  in  the  alimentary  canal." 

Mushrooms  have  a  tempting  flavor,  which  is  developed  on  cook- 
ing, and  while  they  agree  with  most  persons  in  health  and  form  an 
acceptable  article  of  diet,  there  are  some  who  never  can  eat  even  the 
simplest  varieties  without  suffering  more  or  less  from  acute  gastro- 
intestinal irritation.  They  should  never  be  eaten  raw.  They  are 
usually  served  alone,  broiled  upon  toast  or  as  a  dressing  for  beef  fillet, 
steak,  etc.,  or  they  may  be  preserved  in  olive  oil  or  by  drying.  Their 
digestion  requires  fully  three  hours.  The  common  mushroom  con- 
sists of  01  per  cent  water,  besides  31/2  per  cent  of  carbohydrates,  and 
4  per  cent  of  proteid,  with  salts  and  other  substances. 

Truffle*. —  The  truffle  is  a  subterranean  fungus  of  the  order  of 
pliore.  Tt  is  an  expensive  luxury,  and  is  used  to  add  flavor  in 


VEGETABLE  FOODS  225 

cooking  and  as  an  ingredient  of  rich  meat  sauces,  pates,  etc.  It  con- 
tains no  sugar.  Eaten  in  quantity  by  itself  it  is  a  highly  indigestible 
substance.  It  easily  decomposes  with  a  very  offensive  nauseous  odor. 
There  are  several  varieties,  of  which  the  black  is  the  chief,  and  it  is 
obtained  from  beneath  the  trees  of  oak  forests  of  Perigord  in  Southern 
France,  where  it  is  hunted  by  trained  Spanish  poodles  or  sows,  whose 
sense  of  smell  enables  them  to  detect  the  fungus  beneath  the  ground. 
There  is  a  special  hereditary  race  of  truffling  swine,  broken  for  the 
purpose. 

The  morel  is  a  friable,  grayish-black,  cone-shaped  mushroom,  which 
grows  extensively  in  a  variety  of  dry  soils,  but,  like  the  cepe,  is  ob- 
tained principally  in  France.  It  may  be  cultivated  artificially.  It  is 
used  for  flavoring,  like  the  truffle. 

Cepe  is  a  name  given  to  several  edible  mushrooms  belonging  to  the 
Boletus  family,  which  are  globular  in  shape,  and  colored  orange  or 
white. 

The  chantreul  is  a  large  orange-colored,  cup-shape  fungus  eaten  ex- 
tensively in' France,  but  also  in  this  country.  It  flourishes  in  New 
England  in  August. 

Poisonous  Fungi. —  Most  poisonous  fungi  are  distinguished  from 
the  non-poisonous  by  a  warty  cap  and  bulbous  stem.  They  are  often 
viscid  and  have  other  peculiarities  of  structure,  color,  etc.  They  are 
acrid  or  astringent,  and  have  a  pungent,  disagreeable  odor.  Poison- 
ous mushrooms  may  either  produce  violent  gastrointestinal  symp- 
toms, which  are  seldom  fatal,  owing  to  the  prompt  evacuation  of  the 
poison  from  the  system,  or  these  symptoms  are  followed  by  a  condi- 
tion of  narcosis  ending  in  fatal  collapse.  The  pupils  are  contracted, 
the  urine  is  suppressed,  the  face  is  livid,  and  there  is  general  vaso- 
moter  paralysis.  The  conjunctivas  are  congested. 

Muscarin  is  a  substance  isolated  from  poisonous  fungi,  which  is  a 
violent  cardiac  poison  and  constrictor  of  the  pulmonary  blood  vessels, 
producing  dyspnoea,  prostration,  and  death.  Its  effects  are  antag- 
onized by  belladonna. 

Lichen 

Iceland  moss  (Cetraria)  is  used  extensively  as  a  food  by  dwellers  in 
the  Arctic  regions. 

Kb'nig  gives  the  percentage  composition  of  the  dried  moss  as  fol- 
lows: AVater,  15.96;  nitrogenous  matter,  2.19;  fat,  1.41;  non-ni- 
trogenous matter,  76.12. 

A  bread  is  made  from  it  after  carefully  washing  out  two  bitter  or* 
ganic  acids  which  it  contains.  Senator  has  recommended  it  for 

diabetics. 

17 


226  FOODS  AND   FOOD   PREPARATIONS 

Nuts 

Nuts  contain  protein,  with  some  starch,  more  or  less  fat,  and  very 
little  water.  From  50  to  65  per  cent  of  the  common  nuts  is  shell. 
With  the  exception  of  the  cocoanut,  chestnut,  almond,  and  Englisli 
walnut,  the  varieties  eaten  in  this  country  furnish  little  nutriment. 
Their  chief  value  is  to  stimulate  the  appetite  and  afford  variety  in  the 
diet.  Excepting  chestnuts  and  cocoanuts,  they  are  usually  eaten  raw, 
as  dessert,  but  they  are  much  used  in  confectionery.  A  few  nuts  are 
used  in  salads  and  as  dressing  for  fowl.  As  a  rule,  they  are  to  be 
proscribed  from  invalid  dietaries,  but,  with  the  exception  of  chestnuts 
and  peanuts,  they  may  be  allowed  to  diabetics.  A  preparation  of 
malted  nuts  which  may  be  obtained  in  market  is  both  nutritious  and 
digestible.  It  contains  emulsified  nut  fat,  maltose,  and  vegetable 
protein. 

Almonds  contain  a  ferment  called  emulsin  and  much  fat,  and  sweet 
almonds  have  3  to  5  per  cent  of  sugar,  but  no  starch  (Bauer).  This 
low  percentage  of  sugar  makes  them  of  service  in  the  treatment  of 
diabetes,  in  which  disease  they  sometimes  are  used  as  a  substitute  for 
bread  after  being  ground  into  meal.  (See  Diabetic  Breads.) 

Macaroons  are  a  digestible  form  of  cake  for  convalescents  and  chil- 
dren, composed  chiefly  of  almonds  and  sugar. 

Almonds  are  wholesome  and  nutritious.  They  should  not  be  eaten 
in  cases  of  gastric  irritability,  but  occasionally  dyspeptics  in  whom 
gastric  digestion  is  slow  derive  benefit  from  eating  a  few  salted  al- 
monds with  meals.  They  should  be  soaked  and  peeled  or  "  blanched," 
otherwise  their  skins  may  set  up  gastric  irritation. 

The  bitter  almond  contains  hydrocyanic  acid,  sugar,  and  oil,  and 
is  not  used  except  for- flavoring  cough  mixtures.  Almonds  are  im- 
ported chiefly  from  Italy,  France,  and  Spain,  but  of  recent  years  they 
have  been  extensively  grown  in  California. 

English  walnuts  eaten  liberally  between  meals  may  assist  in  over- 
coming constipation  through  the  bulk  of  insoluble  residue  which  they 
leave,  and  possibly  also  from  the  oil  which  they  contain. 

Cocoanuts  are  very  indigestible  even  when  thoroughly  desiccated 
and  grated.  The  cocoanut  contains  a  proteolytic  ferment  which  con- 
verts moat  into  albumoses  with  considerable  activity.  The  cocoanut 
has  been  successfully  grown  in  Florida. 

Brazil  nuts,  pccnn  nuts,  beechnuts,  hazel  nuts,  hickory  nuts,  pine 
nuts,  butternuts,  flberts,  etc.,  all  hold  much  oil,  and  are  difficult  of 
digestion.  Butternut?  easily  become  rancid  after  being  shelled. 

Chestnuts  contain  lo  per  cent  of  sugar  with  so  much  starch  that 


VEGETABLE  FOODS 


227 


they  are  highly  nutritious,  and  in  some  parts  of  Italy  they  are  made 
into  cakes  and  eaten  by  the  peasants  as  a  substitute  for  potatoes. 
Raw  chestnuts  are  highly  indigestible,  but  if  thoroughly  roasted  or, 
better  still,  if  long  boiled,  they  become  much  less  so.  They  should, 
however,  not  be  given  to  invalids. 

The  pistachio,  a  native  nut  of  Syria,  has  a  greenish,  almond-like 
kernel.  It  is  chiefly  used  in  confectionery  and  ices  for  both  its  color 
and  delicate  flavor. 

Acorns  are  used  as  a  food  in  some  countries.  Americus  Vespucius 
in  his  voyage  to  Brazil  in  1499  drank  a  wine  distilled  from  acorns  and 
wrote  of  them :  "  They  are  a  very  good  fruit,  savory  to  the  taste  and 
healthful  to  the  body/'  Like  the  chestnut  they  are  rich  in  starch. 

Peanuts  are  described  under  Legumes,  p.  195. 

Composition  of  Nuts   (C.  F.    Langworthy). 


Refuse. 

Edible 
portion. 

Composition  and  Fuel  Value  of  the  Edible  Portion 

Water. 

c 
£ 

2 

OH 

Fats. 

Car- 
bohy- 
drates. 

Ash. 

Fuel 
value 
per 
pound. 

\lmonds                 

Per  ct. 
64.8 
49.6 
52.1 
62.2 
53.2 
58.0 
16.0 
24.0 
35.6 
40.8 
86.4 
74.1 
48.8 

Per  ct. 
35.2 
50.4 
47.9 
37.8 
46.8 
42.0 
84.0 
76.0 
64.4 
59.2 
13.6 
25.9 
51.2 
100.0 
100.0 

59.4 
75.5 
67.4 
58.4 

Per  ct. 
4.8 

5.3 
3.7 
3.7 
3.0 
2.8 
45.0 
5.9 
4.1 
4.0 
4.5 
2.5 
14.1 
3.5 
4.2 

3.4 
9.2 
1.6 
17.9 

Per  ct. 
21.0 
17.0 
15.6 
15.4 
11.0 
16.7 
6.2 
10.7 
8.1 
21.9 
27.9 
27.6 
5.7 
6.3 
22.6 

14.6 
25.8 
30.5 
2.9 

Per  ct. 
54.9 
66.8 
65.3 
67.4 
71.2 
64.4 
5.4 
7.0 
37.4 
57.4 
61.2 
56.3 
50.6 
57.3 
54.5 

61.9 
38.6 
49.2 
.2 

Per  ct. 
17.3 
7.0 
13.0 
11.4 
13.3 
14.8 
42.1 
74.2 
48.0 
13.2 
3.4 
11.7 
27.9 
31.6 
15.6 

17.3 
24.4 
16.2 
77.5 

Per  ct. 
2.0 
3.9 

2.4 
2.1 
1.5 
1.3 
1.3 
2.2 
2.4 
3.5 
3.0 
1.9 
1.7 
1.3 
3.1 

2.8 
2.0 
2.5 
1.5 

Cal. 
3,030 
3,329 
3,432 
3,495 
3,033 
3,305 
1,125 
1,875 
2,718 
3,263 
3,371 
3,105 
2,986 
3,125 
3,010 

3,364 
2,560 
3,177 
1,453 

Brazil  nuts    

Filberts     

Hickory  nuts  

Pecan   nuts    

English    walnuts      .    ... 

Chestnuts,    fresh     
Chestnuts     dried      .    ... 

Acorns     

Beechnuts     

Butternuts     

\Valnuts          

Cocoanuts     

Pine      nuts      or      pinons 
(Pinus    edulis)     

40.6 
24.5 
32.6 
41.6 

Peanuts,    raw    

Peanuts,   roasted    

Litchi   nuts    

"  The  meat  of  nuts,  excepting  chestnuts  and  cocoanuts,  contains 
nearly  50  times  as  much  fat  and  less  than  one-fifth  as  much  carbo- 
hydrates as  wheat  flour,  and  has  about  double  the  fuel  value  —  i.  e., 
energy-producing  power.  A  pound  of  unshelled  nuts  will  furnish 
about  half  as  much  protein  and  the  same  amount  of  energy  as  a  pound 
of  flour.  Owing  to  their  high  fuel  value  and  low  protein  content, 
nuts  would  not  make  a  well-balanced  food  when  eaten  by  themselves  " 


228         FOODS  AND  FOOD  PREPARATIONS 

(C.  F.  Langworthy).  Eaten  with  fruit,  however,  they  are  an  ex- 
cellent form  of  food,  and  if  carefully  selected  and  thoroughly  masti- 
cated their  coefficient  of  digestibility  is  high  for  persons  in  health,  and 
they  furnish  very  little  residue  of  waste.  The  relatively  high  price 
of  nuts  as  a  food  is  offset  by  the  fact  that  they  demand  no  expense 
for  cooking.  A  number  of  savage  tribes  live  almost  exclusively  upon 
fruits  and  nuts. 

V.  FATS  AND  OILS 

Fats  and  oils  contain  only  three  elements  —  namely,  carbon,  oxy- 
gen, and  hydrogen.  In  the  starches  and  sugars  the  proportion  of 
oxygen  and  hydrogen  is  such  as  to  form  water,  H20,  when  their 
molecules  are  split  up ;  but  in  the  group  of  fats  oxygen  is  not  present 
in  sufficient  quantity  to  form  water  with  all  the  hydrogen  atoms,  and 
in  their  combustion  with  oxygen  considerable  heat  is  evolved.  In 
some  fats,  like  butter,  very  little  oxygen  is  present,  and  carbon  and 
hydrogen  compose  the  bulk  of  the  substance.  The  amount  of  fat 
which  from  time  to  time  is  stored  in  the  body  is  regulated  to  a  greater 
degree  than  any  other  substance  by  muscular  exercise,  which,  if  ac- 
tive, always  tends  to  prevent  its  accumulation.  The  storage  of  fat  is 
favored  by  sleep  as  well  as  inactivity.  (See  Obesity  and  Leanness.) 

About  one-fifth  of  the  entire  body  weight  is  composed  of  fat,  but 
only  about  a  quarter  of  an  ounce  is  contained  in  the  blood.  Before 
death  results  from  starvation  90  per  cent  of  the  body  fat  is  consumed. 
The  chief  sources  of  this  fat  in  the  human  body  are  undoubtedly 
starches  and  sugars,  but  it  is  probable  that  under  certain  conditions 
it  also  may  be  derived  from  fatty  food. 

Besides  the  visible  fat  found  in  meat,  such  as  suet,  etc.,  it  con- 
tains smaller  particles  in  its  substance. 

Fat  is  required  to  promote  the  earlier  stages  of  growth  and  de- 
velopment of  the  organism,  and  there  are  also  many  forms  of  disease 
and  degenerative  changes  which  are  accompanied  by  increased  accu- 
mulation or  production  of  fat  in  and  between  the  tissues  and  cells. 
It  is  as  impossible  to  live  in  perfect  health  without  fatty  food,  as  it 
is  to  live  long  upon  fat  alone,  for  eaten  in  bulk  it  soon  disorders 
digestion. 

Uses  of  Fats. —  The  chief  uses  of  fats  are:  1.  To  furnish  energy 
for  the  development  of  heat.  2.  To  supply  force.  3.  To  serve  as 
covering  and  protection  for  the  body.  4.  To  make  more  plastic  vari- 
ous structures  of  the  body  and  give  rotundity  to  the  form.  5,  To 
spare  the  tissues  from  disintegration,  for,  although  the  combustion 


FATS  AND   OILS  229 

of  fats  in  the  body  results  largely  in  the  production  of  heat,  they 
probably  take  part  to  a  limited  extent  in  tissue  formation.  6.  To 
serve  for  storage  of  energy. 

The  value  'of  fat  food  consists  undoubtedly  in  its  highly  concen- 
trated body  fuel  and  its  power  of  saving  other  tissues,  especially  the 
albuminous,  from  destruction  by  oxidation,  whereas  its  secondary  use 
is  in  connection  with  tissue  formation,  for  fats  enter  into  the  com- 
position of  many  different  tissues,  even  those  of  the  nervous  system. 

Fat  yields  2^4  times  the  fuel  energy  derivable  from  either  proteids 
or  carbohydrates. 

The  fats  and  oils  which  are  employed  as  food  all  serve  essen- 
tially the  same  purpose,  and  may  therefore  be  grouped  together  as 
a  distinct  class.  There  is  a  general  resemblance  in  their  physical 
properties,  although  they  differ  considerably  in  the  melting  point. 
The  several  food  fats  and  oils  are  of  various  chemical  composition, 
but  after  being  absorbed  they  are  recognized  mainly  in  one  or  two 
simple  forms,  chiefly  as  stearin  and  olein. 

It  is  not  possible  to  get  very  much  nourishment  into  the  body 
by  osmosis  through  the  integument,  but  some  improvement  seems  to 
follow  the  rubbing  of  fats  and  oils,  such  as  cacao  butter,  olive  oil,  or 
cod-liver  oil  through  the  skin  of  marasmic  children  and  other  ema- 
ciated patients.  (See  Marasmus.)  One  or  two  teaspoonfuls  of  the  oil 
may  be  rubbed  in  twice  a  day  on  the  thighs,  abdomen,  and  chest.  The 
statement  that  the  application  of  fats  to  the  surface  of  the  body  by 
inunction  reduces  the  body  temperature  is  not  substantiated  by  expe- 
rience. The  use  of  animal  oils,  such  as  lanolin,  and  of  the  petroleum 
products,  like  purified  vaseline,  has  very  largely  superseded  the  ex- 
ternal application  of  other  fatty  substances  —  lard,  etc. —  to  the  skin 
for  the  purpose  of  lubrication. 

The  treatment  of  biliary  calculi  by  the  administration  of  large 
doses  of  olive  oil  —  two  or  three  ounces  at  a  time  —  given  upon  an 
empty  stomach,  has  been  suggested,  apparently  with  the  idea  that  it 
might  have  some  local  lubricating  action.  Cases  have  been  reported 
in  which  gallstones  have  been  said  to  appear  in  the  feces  as  a  result 
of  this  treatment,  but  it  has  been  shown  that  the  oil  may  become 
mixed  with  inspissated  intestinal  mucus  and  form  small,  hard- 
ened masses,  which  have  been  mistaken  for  gallstones.  There  is  no 
foundation  for  the  belief  that  oil  is  of  any  value  for  cholelithiasis, 
nor  is  it  possible  that  it  should  enter  the  bile  ducts  to  "  lubricate  " 
them. 

Fats  and  oils  are  useful  preservatives  of  many  foods  by  prevent- 
ing access  of  air,  drying,  and  decomposition.  A  layer  of  oil  floating 


230          FOODS  AND  FOOD  PREPARATIONS 

on  top  of  a  flask  of  wine  is  capable  of  preserving  its  delicacy  of  flavor 
for  a  long  time.  Oil  preserves  fish,  like  sardines,  and  layers  of  lard 
are  used  to  protect  jars  of  potted  meat,  pate-de-foie-gras,  etc.  Oils 
and  butter  protect  eggs  from  decomposition. 

Digestibility  of  Fats. —  There  is  some  difference  of  opinion  as 
to  what  extent  fat  may  aid  or  "retard  the  process  of  digestion,  but  it 
is  a  matter  of  common  experience  that  those  persons  whose  digsstive 
organs  are  feeble  do  not  tolerate  fats  or  oils  well  when  eaten  with 
other  forms  of  food.  This  is  no  doubt  owing  to  the  fact  that  fats  are 
practically  unaltered  in  the  mouth  and  stomach,  and  in  the  latter, 
when  melted,  they  coat  the  mucous  membrane  and  surround  the  parti- 
cles of  food  with  a  thin  film  which  materially  interferes  with  the 
normal  action  of  the  gastric  juice.  For  this  reason  most  fats  are  to 
be  avoided  by  dyspeptics,  and  the  fats  selected  for  special  nutritive 
processes  should  be  in  the  form  of  good  butter,  cream,  or  cod-liver 
oil.  On  the  other  hand,  fats  sometimes  may  aid  the  digestibility  of 
starchy  foods  by  preventing  them  from  forming  lumpy  masses  in  the 
mouth  and  stomach.  For  example,  a  well-roasted  mealy  potato  may  be 
made  all  the  more  digestible  for  an  invalid  by  being  mashed  with  a 
little  butter  or  cream.  The  digestibility  of  fats  may  be  much  en- 
hanced by  the  process  of  emulsification  —  i.  e.,  of  securing  an  ex- 
tremely fine  subdivision  of  the  oil  globules,  provided  pancreatic 
extract  or  fresh  pancreas  is  used,  but  the  so-called  mechancial  emul- 
sions made  with  lime  salts,  gum  arabic,  sugar,  etc.,  are  of  little  value. 
More  than  fifty  years  ago  Horace  Dobell,  of  London,  emulsified 
beef  fat  and  lard  by  means  of  pancreatic  juice,  and  recently  John  F. 
Russell,  of  Xew  York,  has  modified  and  extended  the  principle  so 
as  to  emulsify  all  fats,  fluid  or  solid,  deriving  products  of  permanent 
fine  emulsion,  capable  of  dilution  with  hot  water,  and  possessing  high 
nutritive  value.  These  emulsions  consist  of  one-half  fat,  which  is 
predigested  and  easily  assimilated. 

Most  of  the  fat  used  as  food  melts  at  the  temperature  of  the  body, 
which  facilitates  its  digestion. 

As  a  rule  the  stomach  is  less  disturbed  by  animal  than  by  vege- 
table fats  taken  in  excess,  and  the  former  may  be  tolerated  for  a 
longer  time.  The  limit  of  digestibility  of  increasing  quantities  of 
food  is  much  sooner  reached  with  fats  than  with  other  articles  of 
diet,  and  they  produce  satiety  early  in  a  meal,  but,  as  in  the  case  of 
many  foods,  toleration  may  be  acquired  for  the  ingestion  of  fat,  which 
is  exemplified  in  the  fact  that  many  persons  who  cannot  digest  cod- 
liver  oil  completely  at  first  may  do  so  after  two  or  three  weeks'  trial. 
Overdoses  of  fat  at  any  time  are  apt  to  give  rise  to  the  formation  of 


FATS  AND   OILS  231 

irritating  acids  which  cause  nausea  and  vomiting,  with  possibly  ab- 
dominal cramps  and  loose  evacuations. 

Since  fat  is  exclusively  digested  in  the  small  intestine,  diseases 
of  any  part  of  the  alimentary  canal  are  contraindications  for  its 
use. 

The  digestibility  of  all  fat  depends  somewhat  upon  its  cooked  state. 
Many  persons  are  nauseated  or  made  dyspeptic  by  eating  hot  mutton 
fat  who  can  eat  the  same  with  impunity  when  it  is  cold.  In  the  latter 
condition  it  becomes  more  friable,  and,  if  thoroughly  mixed  in  chew- 
ing with  starchy  food,  or  used  as  suet  in  the  form  of  a  farinaceous 
pudding,  it  becomes  much  more  digestible.  Children  usually  dislike 
fat  meat,  but  they  are  quite  willing  to  take  suet  puddings,  which,  if 
light  and  well-cooked,  are  wholesome.  They  usually  prefer  butter  to 
any  other  form  of  fat  except  cream. 

Although  the  various  fats  and  oils  in  general,  have  the  same  bene- 
ficial effect  upon  nutrition,  there  is  considerable  difference  in  their 
force  value  and  in  the  facility  with  which  one  variety  or  another  may 
be  assimilated  in  individual  cases.  The  animal  fats  have  a  higher 
nutritive  power  than  those  derived  from  vegetables,  and  suet,  butter 
and  cream,  are  the  most  serviceable  of  all. 

Liquefied  fats  and  oils  are  usually  administered  as  a  matter  of 
routine  when  corrosive  poisons  have  been  swallowed,  with  the  idea 
that  they  coat  over  the  mucous  membrane  of  the  stomach  and 
oesophagus  and  protect  them  from  the  action  of  the  irritant.  This 
protective  action  is  overestimated,  for  it  is  difficult  to  coat  to  a  suffi- 
cient degree  a  mucous  membrane  which  is  already  moistened  with 
watery  mucus. 

Animal  Fats. —  The  principal  animal  fats  and  fatty  foods  are 
butter,  cream,  suet,  lard,  oleomargarine,  the  fat  of  beef,  mutton,  pork 
and  bacon,  bone  marrow,  pemmican,  fish,  and  cod-liver  oil.  Fat  is 
also  a  constituent  of  the  yolk  of  eggs. 

Butter  and  cream  have  been  discussed  under  the  heading  Milk 
Derivatives  (pp.  108-112). 

Lard  is  hog  fat  separated  by  melting  from  the  areolar  connective 
tissue.  Considerably  over  half  a  billion  pounds  are  annually  pro- 
duced in  the  United  States.  Crude  lard  contains  glycerides  of  oleic, 
stearic,  and  palmitic  acids,  besides  a  little  gelatin  and  other  sub- 
stances. 

"  Cuisine  "  is  a  preparation  of  cotton-seed  oil  designed  to  replace 
lard  and  cheap  cooking  butter. 

"  Cottohne  "  is  another  substitute  used  for  cooking. 

Stearins  are  the  solid  residue  of  animal  fats  remaining  after  pres- 


232         FOODS  AND  FOOD  PREPARATIONS 

sure  has  separated  the  fluid  fats.     They  are  used  in  making  com- 
pound lard,  butterine,  and  similar  foods. 

Suet  is  the  fat  which  surrounds  the  kidneys  of  the  ox,  sheep,  and 
other  animals. 

Oleo  oil  is  made  from  the  rich  caul  fat  of  the  steer. 

Oleomargarine. —  Oleomargarine  was  invented  in  1870  by  a  French 
chemist,  Mege-Mourier,  who  discovered  that  beef  fat  from  certain  por- 
tions of  the  bullock  would  melt  at  the  same  temperature  with  butter, 
and  would  keep  longer  without  becoming  rancid.  It  was  patented  in 
the  United  States  in  1873.  The  fresh  fat  is  mashed  in  a  grinding 
machine  to  free  it  from  membrane.  "  The  fragments  fall  into  a  tank 
heated  with  steam,  which  for  every  thousand  part  of  fat  contains 
three  hundred  parts  of  water  and  one  part  of  carbonate  of  potash  and 
two  stomachs  of  sheep  or  pigs.  The  temperature  of  the  mixture  is 
raised  to  45°  C."  (Clark).  After  two  hours  the  fat  is  withdrawn 
from  the  membranes,  which  have  been  digested  away,  and  is  heated 
still  more  with  the  addition  of  2  per  cent  of  salt.  It  is  then  cooled, 
pressed,  and  packed  for  market. 

The  Internal  Revenue  Commissioner  has  published  its  composition 
as  follows: 

Composition  of  Oleomargarine. 

Per  cent.  Per  cent. 

Neutral    lard    34.37  Stearin    07 

Oleo  oil    26.82  Glucose     03 

Cottonseed    oil    4.77  Milk    15.55 

Sesame    53  Salt     7.42 

Coloring  matter 16  Butter  oil    1.76 

Sugar    12  Butter     1.72 

Glycerin    01  Cream 3.86 

The  volatile  fats  of  oleomargarine  are  5  per  cent,  as  compared  with 
8  per  cent  in  good  butter. 

Much  discussion  has  arisen  in  regard  to  the  wholesomeness  of 
oleomargarine,  and  its  sale  has  been  regulated  by  act  of  Congress 
since  1886  and  by  many  State  la\vs.  It  has  been  declared  perfectly 
innocuous,  and  the  object  of  the  legal  control  of  its  sale  is  mainly 
intended  to  prevent  it  from  being  fraudulently  offered  as  butter.  It 
certainly  tastes  better  than  poor  butter,  and  is  very  digestible. 

Butterine,  which  has  now  largely  replaced  oleomargarine  in  this 
country,  is  made  in  a  similar  manner,  but  with  a  somewhat  different 
proportion  of  ingredients,  and  some  of  the  leaf  fat  of  the  hog  is  added 
during  the  manufacture. 

Beef  Fat,  Fork.  etc. —  Beef,  mutton,  and  pork  fat  consist  princi- 
pally of  the  glycerides  of  such  common  fatty  acids  as  stearic,  palmitic, 
and  oleic. 


FATS   AND   OILS  233 

The  fat  of  good  roast  beef  is  nutritious,  and  a  highly  digestible 
variety  of  fat  is  good  bacon  thinly  sliced  and  thoroughly  cooked. 
This  form  of  fat  is  crisp  and  dry,  and  it  is  often  digested  by  invalids 
who  cannot  tolerate  other  kinds.  Ham  fat  and  pork  fat,  on  the  other 
hand,  are  usually  very  indigestible  —  the  more  so  when  hot. 

Bone  Marrow.-— -  Bone  marrow  is  an  easily  assimilable  fat  which 
has  long  been  used  as  a  food.  The  long  bones  of  the  ox  are  cut  cross- 
wise in  pieces  about  two  inches  in  length  and  cooked  with  the  marrow 
within  them.  Red  marrow  is  a  useful  food  in  cases  of  tuberculosis, 
secondary  and  pernicious  anaemia,  and  chlorosis.  It  contains  consid- 
erable iron.  The  marrow  of  young  animals,  such  as  the  calf  or  lamb, 
is  preferred  for  this  purpose,  because  their  tissue-building  power  is  so 
active. 

J.  S.  Billings,  Jr.,  recommends  a  preparation  made  from  sheep's 
ribs,  chopped,  rubbed  in  a  mortar  with  glycerin,  macerated  and 
strained. 

Henry  ~F.  "\Valker,  of  New  York,  uses  a  preparation  made  by  mix- 
ing thoroughly  the  red  marrow  of  the  long  bones  of  the  ox  with 
Cetraria  (Iceland  Moss).  This  makes  an  agreeable  whitish  paste 
pleasant  to  the  eye,  and  tasting  not  unlike  good  butter.  It  may  be 
spread  upon  bread  and  eaten  three  or  four  times  a  day. 

Pemmican  is  made  of  meat  cut  into  slices  and  thoroughly  dried  in 
the  sun;  to  this  are  added  fat,  sugar,  and  dried  fruit,  such  as  raisins 
and  currants.  It  is  used  on  long  voyages,  especially  to  the  Arctic 
circle,  where  a  fatty  diet  is  essential  to  furnish  heat  and  force  to 
enable  the  body  to  withstand  the  rigor  of  the  climate.  It  is  easily 
masticated,  and  the  sweet  fruit  promotes  the  flow  of  saliva. 

Calves'  brains  and  liver  contain  considerable  fat. 

The  common  fish  which  furnish  most  fat  are  eels,  salmon,  herring, 
and  mackerel.  Sardines  contain  some  fat,  but  derive  most  of  it  from 
the  oil  in  which  they  are  immersed  for  preservation. 

Many  fish  oils  have  special  uses.  The  Eskimos  eat  whale  and  seal 
oil  and  blubber,  and  dugong  oil  is  eaten  to  some  extent  in  Australia. 
The  oil  of  the  sturgeon  is  employed  for  preserving  caviare.  Turtle 
oil  arid  butter  is  made  extensively  in  Brazil  from  both  the  eggs  and 
fat  of  the  animal  (Clark). 

Cod-liver  oil  is  separately  considered  on  page  235. 

Eggs  contain  considerable  fat  in  their  yolks.  Some  eggs,  like  the 
plover's,  are  very  rich  in  this  ingredient.  They  are  described  in  de^ 
tail  on  page  120. 

Lecithin  is  a  form  of  fat  contained  in  a  variety  of  animal  cells, 
but  predominating  in  eggs  and  brains.  Various  preparations  of  it 
18 


234         FOODS  AND  FOOD  PREPARATIONS 

have  been  placed  on  the  market  as  food,  but  it  is  best  to  administer 
it  through  modification  of  the  dietary  by  increased  use  of  such  foods 
as  eggs  and  calves'  brains. 

Vegetable  Fats  and  Oils. —  The  principal  vegetable  fats  or  oils  and 
fatty  foods  are  derived  from  seeds.  Such  foods  are  olives,  olive  oil, 
cotton-seed  oil,  and  nuts.  Traces  of  fat  are  found  in  the  legumes. 

Olive  Oil. —  Olives  and  olive  oil  constitute  a  very  digestible  form 
of  fatty  food,  and  may  sometimes  be  eaten  by  consumptives  in  lieu 
of  cod-liver  oil.  French  olives  gathered  while  young  and  tender  are 
wholesome. 

Olive  oil  is  made  by  crushing  the  fruit  with  stones,  after  which 
the  pulp  is  pressed  in  bags.  The  first  oil  thus  obtained  is  the  best. 
A  second  oil  is  got  by  adding  boiling  water  to  the  pulp  residue,  and 
pressing  it  again.  This  oil  is  more  likely  to  become  rancid  than  the 
first  (Clark).  The  best  oil  generally  obtainable  comes  from  France 
and  Italy,  but  an  excellent  quality  is  manufactured  in  Southern  Cali- 
fornia. The  paler  variety  is  preferable,  but,  unfortunately,  it  is  con- 
stantly adulterated  or  imitated.  (See  Olives,  p.  221.)  Olive  oil  is 
eaten  with  salads,  and  is  also  useful  for  frying. 

Cotton-seed  oil,  and  to  some  extent  poppy-seed  oil,  are  now  fre- 
quently substituted  for  olive  oil  in  the  preparation  of  various  foods, 
and  the  sardines  which  were  formerly  preserved  in  pure  olive  oil  are, 
for  the  most  part,  immersed  in  cotton-seed  oil.  This  oil  is  not  ran- 
cid, but  its  flavor  and  odor,  which  resemble  linseed  oil,  are  not  agree- 
able when  it  is  eaten  raw  with  salads  or  fish,  and,  unless  extremely 
pure,  it  leaves  an  unpleasant  after-taste  in  the  mouth.  It  is  com- 
posed principally  of  palmitin  and  olein.  It  is  a  harmless  food. 

Linseed  oil  is  sometimes  substituted  for  olive  oil,  but  is  not  as 
digestible. 

Cacao  I  utter,  oil  of  theobroma,  is  a  firm  oil  obtained  from  cacao 
seeds  during  the  manufacture  of  chocolate.  It  easily  melts  at  the 
body  temperature.  It  is  used  for  inunctions  and  for  making  sup- 
positories, and  sometimes  as  an  ingredient  of  infant  foods,  such  as 
Lacto-prcparata  (p.  107). 

Nuts,  especially  English  walnuts,  cocoanuts,  hickory,  pecan,  and 
Brazil  nuts,  all  contain  considerable  vegetable  oil.  (See  Nuts, 
p.  226).  The  oil  of  nuts  which  have  been  too  long  kept  sometimes 
becomes  rancid  and  unwholesome. 

Cocoanitt  oil  is  principally  used  in  Oriental  countries. 

Peanut  oil  is  used  to  some  extent  in  this  country,  like  cotton-seed 
oil.  mainly  to  adulterate  or  imitate  olive  oil. 

Java  almond  oil  also  may  be  used  for  cooking. 


FATS  AND  OILS  235 

The  "  Blossom  "  fat  food  is  made  in  the  Philippines  by  Captain 
J.  E.  Bloom,  U.  S.  A.,  from  the  "  pile  nut/'  which  grows  upon  a  tree 
in  Luzon.  From  this  nut  an  oil  is  extracted  by  hydraulic  pressure 
which  is  combined  with  olein  from  lard  and  palmitin  from  cotton- 
seed oil,  also  extracted  by  pressure  under  certain  conditions  of  tem- 
perature. The  resulting  product  is  said  to  be  well  tolerated  by  the 
stomach,  and  constitutes  a  highly  nutritious  food. 

Dietetic  Uses  of  Fats  and  Oils. —  Because  fats  are  essential  for 
growth  and  nutrition  as  well  as  force  production,  fatty  food  is  in- 
dicated for  convalescence  from  severe  acute  diseases,  and  for  patients 
suffering  from  chronic  wasting  diseases.  Persons  whose  general 
health  has  been  impaired  by  poor  hygienic  surroundings,  children 
who  have  been  wrongly  fed  by  ignorant  or  poor  parents,  and  aged  per- 
sons in  whom  the  nutritive  processes  are  becoming  less  and  less  vigor- 
ous, may  all  be  benefited  by  supplying  a  sufficient  quantity  of  fatty 
food  in  the  dietary. 

Diseases  in  Which  Fats  are  Most  Beneficial. —  There  is  a  large 
number  of  diatheses  and  diseases,  both  local  and  general,  which  may 
be  benefited  by  improving  the  nutrition  of  the  body  and  increasing 
force  production  through  the  agency  of  easily  digestible  forms  of  fat. 
(See  Appendix  for  list  of  Fat  Foods.)  Such  are:  Tuberculosis, 
pulmonary  as  well  as  other  forms;  anaemia;  chronic  wasting  diseases 
with  secretion  of  pus,  as  empyema,  chronic  abscesses,  etc.;  maras- 
mus; rickets;  chronic  bronchitis;  many  chronic  diseases  of  the  skin 
and  nervous  system;  diabetes. 

Diseases  in  Which  the  Use  of  Fats  Should  Be  Forbidden  or  Re- 
stricted.—  All  forms  of  acute  gastrointestinal  disease ;  chronic  gas- 
tritis; dilatation  of  the  stomach;  chronic  diarrhoea;  obesity;  fatty  and 
waxy  liver;  gallstones;  acne;  urticaria;  eczema. 

Generally  speaking,  fats  are  laxative,  and  by  most  persons  fat  can- 
not be  eaten  continuously  in  large  quantities  without  producing  indi- 
gestion. The  stools  become  offensive  and  diarrhceal,  there  is  nausea 
and  gastric  indigestion,  and  disgust  for  such  a  diet  very  soon  arises. 
There  are  those  who  are  unable*  to  digest  fats  in  any  degree,  however 
small,  and  they  must  derive  their  energy  from  carbohydrates. 

Glycerin. —  Glycerin  plays  an  inconspicuous  role  as  a  food.  It 
is  mainly  used  for  its  sweetish  taste  as  a  substitute  for  sugar  in  the 
diet  of  diabetics,  but  to  many  persons  the  taste  of  glycerin  itself  is 
nauseous.  It  is  now  largely  superseded  by  saccharin.  It  is  hygro- 
scopic, and  if  taken  in  the  mouth  undiluted  makes  the  mucous  mem- 
brane sticky  and  unpleasant,  but  it  is  used  as  a  mouth  wash  in  a 
diluted  form  in  the  proportion  of  a  drachm  to  the  ounce  of  water. 


236          FOODS  AND  FOOD  PREPARATIONS 

The  mouth  may  be  rinsed  or  swabbed  with  it  in  cases  of  acute  fever, 
such  as  typhoid,  where  the  mucous  surface  has  become  dried  or  the 
tongue  is  glazed  or  fissured.  It  acts  by  protecting  the  mucous  mem- 
brane from  evaporation,  making  the  mouth  more  comfortable.  In 
such  cases  it  sometimes  diminishes  thirst,  although  its  effect  in  this 
respect  is  very  uncertain.  Glycerin  is  also  laxative,  and  it  may  be 
given  either  per  os,  as  an  enema  or  in  the  form  of  the  well-known 
glycerin  suppositories  for  the  purpose  of  increasing  peristaltic  action. 

Cod-liver  Oil 

The  best  cod-liver  oil  is  known  as  "cold-drawn  oil,"  and  is  pre- 
pared from  the  raw  fresh  livers  of  the  codfish  by  subjecting  them  to 
heavy  pressure,  by  which  the  oil  is  squeezed  out. 

Chemical  and  Physical  Properties. —  Cod-liver  oil,  according  to 
analyses  made  by  De  Jongh,  contains  glycerin,  olein  (70  per  -cent), 
myristic,  butyric,  acetic,  margaric,  and  other  acids,  biliary  elements 
such  as  cholesterin,  also  iodine,  bromine,  chlorine,  and  phosphorus 
in  small  quantity,  and  a  peculiar  material  which  is  called  "  gaduin." 
Gautier  and  Mourges  obtained,  besides  a  half  dozen  substances  re- 
sembling alkaloids  and  other  materials,  a  basic  substance  which  they 
call  morrhuine,  about  one-half  milligram,  .0075  gram  of  which  oc- 
curs in  each  gram  (15.43  grains)  of  the  oil,  and  has,  it  is  claimed, 
all  of  its  active  medicinal  properties.  The  refined  oil  may  contain 
no  iodine,  and  it  is  seldom  present  in  greater  proportion  than  0.5  per 
cent ;  hence  the  value  of  the  oil  does  not  depend  upon  this  substance, 
as  at  one  time  suggested. 

When  pure,  its  odor  resembles  shoe  leather.  On  adding  strong 
acid,  the  biliary  odor  is  intensified  if  the  oil  is  unadulterated.  If  the 
odor  is  absent,  the  oil  is  spurious. 

Cod-liver  oil  is  one  of  the  most  easily  absorbed  of  all  the  oils,  owing 
to  the  quantity  of  its  fatty  acids.  It  is  quickly  oxidized  in  the  body. 
It  is  highly  nutritious  and  alterative,  and  is  slightly  laxative,  espe- 
cially for  infants. 

Some  of  the  oil  supplied  in  market  is  derived  from  the  livers  of 
other  fishes  than  the  cod,  but  the  cod-liver  oil  is  undoubtedly  the 
best.  Pains  should  be  taken  to  secure  a  pure  preparation  thoroughly 
clarified  from  the  impurities  which  oil  may  contain,  such  as  traces  of 
iodine,  phosphorus,  and  sometimes  bile  salts.  None  of  these  sub- 
stances add  to  its  food  value,  and,  if  present  in  excess,  the  oil  is  much 
more  likely  to  disagree. 

Cod-liver  oil  is  sometimes  adulterated  with  the  cheaper  cotton-seed 
oil.  to  which  a  fishy  flavor  is  artificially  given,  and  it  should  therefore 


FATS  AND  OILS  237 

only  be  purchased  from  a  well-known  and  responsible  firm.  The 
clarified  Norwegian  oil  is  the  best  variety  to  prescribe. 

An  advantage  of  cod-liver  oil  is  that  when  pure  it  may  be  taken 
longer  than  any  other  fat  excepting  butter  and  cream  without  disor- 
dering the  stomach.  This  is  no  doubt  owing  to  the  fact  that  the  oil 
is  already  in  a  condition  in  which  it  has  once  served  in  the  fishes'  body 
for  nutrition  or  at  least  for  storing  up  energy.  This  form  of  oil  is 
readily  emulsified  and  saponified,  and  is  absorbed  by  the  intestinal 
villi  with  great  facility. 

Dosage. —  Many  patients  who  dislike  the  taste  of  the  oil  at  first 
soon  acquire  tolerance  for  it  if  given  in  small  and  gradually  increas- 
ing dosage,  commencing  sometimes  with  not  over  10  to  30  drops 
twice  a  day,  and  children  not  rarely  become  so  fond  of  it  as  to  ob- 
ject to  its  discontinuance.  Infants  may  be  given  from  5  to  20  drops 
two  or  three  times  a  day.  If  it  is  not  digested  at  first,  but  one  dose  of 
two  or  three  teaspoonfuls  a  day  need  be  given,  and  this  should  be  at 
night.  Those  who  like  it  can  sometimes  take  as  much  as  an  ounce 
three  times  a  day  with  advantage,  although  half  an  ounce  is  all  that 
usually  can  be  tolerated. 

Patients  who  dose  themselves  with  it  often  use  too  much,  and  al- 
most invariably  take  it  at  the  wrong  time  in  relation  to  meals. 

It  is  best  to  take  the  oil  about  two  hours  after  dinner.  If  taken 
earlier,  it  remains  in  the  stomach,  interfering  with  the  digestion  of 
other  food,  whereas  if  digestion  is  already  well  under  way,  it  passes 
with  the  chyme  into  the  intestine,  where  it  is  absorbed.  While  the 
oil  is  being  taken  the  stools  should  be  examined  occasionally,  as  the 
absence  of  fat  globules  in  them  is  a  proof  of  its  complete  absorp- 
tion. 

Methods  of  Administration. —  Many  patients  can  take  perfectly 
pure,  well-clarified  cod-liver  oil  better  than  the  emulsions  and  prep- 
arations in  which  it  is  offered  in  the  market,  while  others  prefer  it 
in  the  form  of  the  so-called  emulsions  with  hypophosphites  of  lime, 
soda,  or  iron,  or  with  other  substances.  Some  of  these  emulsions  are 
rendered  almost  tasteless,  while  others  are  flavored  with  wintergreen, 
ginger,  or  some  other  aromatic. 

Emulsions  are  seldom  as  good  as  the  pure  oil,  and  are  only  to  be 
preferred  when  the  latter  is  not  digested  or  when  the  taste  proves  too 
nauseous.  They  usually  do  not  contain  above  50  per  cent  of  the  oil, 
and  often  only  33  per  cent;  hence  the  dose  is  unnecessarily  bulky. 
Moreover,  they  rapidly  deteriorate  with  age,  so  that  if  emulsions  are 
to  be  used  they  should  be  freshly  made  with  yolk  of  egg  and  glycerin 
or  mucilage  of  tragacanth. 


FOODS   AND   FOOD   PREPARATIONS 

The  late  Dr.  James  Stewart,  of  Montreal,  gave  excellent  formulae 
for  this  purpose  as  follows : 

]£  Cod-liver   oil 6  ounces. 

Oil  of  wintergreen    '. 1  drachm. 

Chloroform    2  drachms. 

Glycerin,  yolk  of  egg,   each    5         " 

Orange-flower  water,  sufficient  to  make  12  ounces. 

M.  Dose,  one  tablespoonful. 

]J  Cod-liver   oil    6  ounces. 

Oil  of  wintergreen   ( or  any  essential  oil )    1  drachm. 

Mucilage  of  tragacanth   2  ounces. 

Orange  water,  sufficient  to  make   12        " 

M.  Dose,  one  tablespoonful. 

This  latter  emulsion  is  somewhat  thicker  than  the  preceding  one. 

Oil  of  bitter  almonds  may  be  used  in  the  proportion  of  three  drops 
to  the  ounce,  instead  of  the  wintergreen  oil. 

Lefaki  recommends  an  emulsion  made  with  an  equal  part  of  lime 
water  flavored  with  lemon  sirup  or  vanilla.  This  may  be  prescribed 
when  diarrhoea  exists.  Another  method  is  to  add  two  ounces  of  finely 
chopped  and  strained  fresh  pancreas  to  the  gallon  of  oil  to  produce  an 
emulsion. 

Stewart  suggested  rinsing  the  mouth  before  taking  the  oil  with 
undiluted  brandy  or  whisky  and  two  or  three  drops  of  oil  of  pepper- 
mint. Children  may  be  given  a  peppermint  lozenge.  If  preferred, 
the  dose  of  pure  oil  may  be  poured  upon  the  surface  of  some  fluid, 
such  as  orange  or  ginger  bitters,  strong  black  coffee,  lemon  juice, 
weak  brandy  and  water,  ale  or  beer.  Pains  should  be  taken  to 
float  the  oil  in  the  center  of  the  surface  of  the  fluid,  so  that  it  is 
to  some  extent  coated  by  it  and  does  not  come  in  contact  with  the 
glass  or  cup  and  produce  a  lingering,  disagreeable  taste  in  the  mouth. 
Ringer  suggested  adding  a  few  drops  of  catsup  to  disguise  the  taste, 
or  the  use  of  a  mixture  of  equal  parts  of  the  oil  and  fresh  aqueous 
solution  of  gum  acacia  with  two  minims  of  oil  of  lemons  added  to 
each  ounce.  A  little  salt  taken  in  the  mouth  before  and  after  each 
dose  may  neutralize  the  taste.  He  also  referred  to  the  use  of  a  cod- 
liver-oil  jelly  containing  70  per  cent  of  the  oil.  This  disguises  the 
flavor.  The  oil  is  sometimes  given  with  different  preparations  of 
meat  juice. 

In  this  country  cod-liver  oil  is  extensively  used  in  the  form  of 
capsules  of  gelatin  which  are  shaped  like  an  olive,  and  which  some 
patients  can  swallow  with  ease,  although  they  are  rather  bulky  and 
not  always  reliable.  A  child  of  ten  years  came  under  my  observa- 
tion who  for  sonic  time  previously  had  been  given  four  or  five  of  these 


FATS  AND  OILS  239 

capsules  daily,  each  containing  a  teaspoonful  of  cod-liver  oil.  She 
had  developed  an  exceedingly  irritative  stomach  cough,  for  which  a 
variety  of  sedatives  had  been  administered  without  any  effect;  but 
when  she  at  one  time  vomited  seventeen  of  the  undissolved  capsules, 
which  represented  four  or  five  days'  dosage,  the  cough  ceased. 

The  oil  is  sometimes  administered  in  the  form  of  "  oleochyle,"  in 
which  it  is  claimed  it  has  been  predigested. 

Claude  Bernard  first  showed  that  ether  given  by  the  mouth  acts  as 
a  stimulant  to  the  secretion  of  the  pancreas  and  the  glands  of  Brun- 
ner  which  aid  the  digestion  of  fat,  and  that  it  increases  the  absorp- 
tion of  fats.  Acting  upon  this  suggestion,  Dr.  Balthazer  Foster 
found  that  pure  ether  added  to  fats  and  oils  in  the  proportion  of  five 
or  six  minims  to  a  drachm  of  the  oil  would  often  insure  its  digestion, 
whereas  previously  it  had  excited  nausea  and  vomiting,  and  this 
method  has  proved  of  service  in  the  hands  of  others.  The  ether  itself 
disguises  somewhat  the  taste  of  the  oil,  but  I  have  sometimes  found 
it  to  produce  unpleasant  eructations.  In  fact,  in  some  hospitals  a 
"  malingerer's  mixture "  has  been  employed  composed  of  a  disagree- 
able combination  of  ether,  oil  and  asafoetida,  which  has  the  result  of 
causing  eructations  and  maintaining  an  exceedingly  disagreeable  taste 
in  the  mouth. 

Cod-liver  oil  is  added  in  the  proportion  of  30  per  cent  to  maltine, 
or  50  per  cent  to  malt  extract,  and  when  not  so  sweet  as  to  be  disliked 
by  the  patient  it  proves  a  very  serviceable  food. 

In  very  hot  weather  it  is  usually  best  to  suspend  the  administration 
of  oil,  as  it  is  liable  to  disagree,  even  if  it  does  not  become  rancid. 

Substitutes. —  Many  substitutes  for  cod-liver  oil  have  been  pro- 
posed, but  it  is  doubtful  whether  any  of  them  except  cream  can  be 
made  to  yield  all  the  benefits  to  be  derived  from  the  genuine  substance. 

Efforts  have  long  been  made  to  determine  whether  the  alkaloidal 
or  other  substances  obtainable  from  cod-liver  oil  do  not  possess  all 
the  nutritive  and  stimulating  properties  of  the  oil  itself  in  equal  or 
oven  greater  degree.  Some  of  them  are  doubtless  capable  of  pro- 
ducing active  symptoms,  but  if  the  oil  itself  is  a  true  food,  there  can 
be  no  advantage  in  attempting  to  concentrate  it  beyond  the  minor 
consideration  of  avoiding  its  nauseous,  fishy  taste.  M.  Chapoteau 
describes  a  crystalline  substance  which  he  terms  "morrhuol,"  and 
which  exists  in  the  oil  in  the  proportion  of  1.5  to  6  per  cent,  the 
lesser  quantity  being  found  in  the  purest  oil.  It  is  claimed  that  three 
to  five  drops  of  this  substance  possess  all  the  properties  of  a  drachm 
of  cod-liver  oil.  It  may  be  given  in  capsules  or  disguised  with  olive 
oil,  fat,  or  cream. 


240         FOODS  AND  FOOD  PREPARATIONS 

Von  Mehring  and  Hauser  recommend  "  lipanin  "  made  by  adding 
to  olive  oil  6  per  cent  of  oleic-acid.  It  is  devoid  of  disagreeable  taste 
and  odor,  and  one  to  four  teaspoonfuls  may  be  given  three  times  a  day. 

Uses. —  Cod-liver  oil  is  not  a  specific  for  any  disease,  and  there 
are  many  clinicians  who  prefer  to  prescribe  other  forms  of  fat  when 
possible.  Of  late  years  I  often  prefer  to  prescribe  cream  diluted 
with  Vichy  or  water  in  equal  parts,  or  weaker. 

Nevertheless,  there  are  often  seen  cases  of  phthisis  in  which  a 
decided  gain  in  weight  follows  the  administration  of  a  disproportion- 
ately small  quantity  of  the  oil.  It  is  a  good  food  in  many  conditions 
of  debility,  and  in  the  treatment  of  rickets,  in  a  variety  of  forms  of 
chronic  inflammation  and  in  cases  in  which  there  is  old  purulent  dis- 
charge from  any  part  of  the  body,  as  from  the  middle  ear,  or  from  a 
chronic  abscess,  like  empyema,  and  in  chronic  bone  diseases,  such  as 
caries  and  tuberculosis. 

Among  other  chronic  diseases  for  which  cod-liver  oil  is  recom- 
mended may  be  mentioned  chronic  rheumatism  and  gout,  arthritis 
deformans,  a  variety  of  skin  affections,  and  advanced  syphilis.  It 
is  of  service  also  in  pulmonary  emphysema  and  in  cases  of  chronic 
bronchitis  with  tenacious  purulent  expectoration,  and  by  many  it  is 
believed  to  be  of  some  specific  value  in  loosening  cough.  It  should 
be  observed  that  oil  when  absorbed  passes  through  the  lymphatic 
system  and  is  carried  with  tolerable  directness  into  the  pulmonary 
circulation,  where  fats  in  general  are  believed  to  be  oxidized.  It  is 
suggested  that  this  fact  may  possibly  have  some  bearing  on  the  in- 
fluence attributed  to  cod-liver  oil  as  an  expectorant,  although  it  seems 
more  probable  that  the  effect  is  derived  from  the  improvement  pro- 
duced upon  the  general  nutrition.  Brunton  attributes  it  to  a  stimu- 
lating action  upon  the  epithelium  of  the  bronchi.  In  cases  of  atonic 
dyspepsia,  particularly  among  elderly  people,  cod-liver  oil  often  re- 
lieves the  "sinking  "  feeling  at  the  epigastrium  and  faintness. 

It  is  also  serviceable  in  relieving  constipation  in  young  infants,  and 
it  may  be  given  sometimes  with  advantage  in  lieu  of  castor  oil.  Its 
loosening  effect  is  more  decided  in  children  than  in  adults,  and  it  is 
loss  likely  to  produce  subsequent  constipation  than  castor  oil,  besides 
being  less  disagreeable  to  take. 

For  marasmus  the  use  of  cod-liver  oil  is  particularly  indicated, 
and  in  infants  when  chronic  diarrhoea  obtains,  some  benefit  may  be 
derived  from  the  topical  application  of  the  oil  to  the  skin.  To  tuber- 
culous children  of  the  emaciated  marasmic  type  in  whom  the  skin  is 
dry  and  wrinkled  1 5  or  20  drops  of  the  oil  may  be  given  at  night  with- 
out fear  of  increasing  the  diarrhoea. 


PART  II 

STIMULANTS,  BEVEKAGES,  CONDIMENTS 

STIMULANTS  AND  BEVERAGES 

IT  is  the  almost  universal  experience  of  mankind  that  the  taking 
of  food  and  drink  merely  to  satisfy  the  cravings  of  physical  needs 
does  not  at  the  same  time  wholly  satisfy  the  desire  of  the  mind  for 
occasional  invigoration,  for  restoration  of  bodily  functions  after  fa- 
tigue, for  support  during  sustained  muscular  exertion,  for  an  incen- 
tive to  activity,  and  for  conviviality.  In  some  form  or  other,  al- 
though in  greatly  varying  degree,  a  stimulant  is  demanded  by  almost 
everyone  to  meet  the  emergencies  with  which  he  is  from  time  to  time 
confronted. 

To  this  end  the  civilized  European  imports  his  tea  from  China, 
his  coffee  from  Java,  his  cocoa  from  Brazil,  his  tobacco  from  America 
or  Cuba,  his  opium  from  India,  and  his  alcohol  from  more  immediate 
neighbors.  His.  semicivilized  or  wholly  barbaric  brother  who  lacks 
the  ability  or  means  to  procure  such  refreshment  from  foreign  sources 
relies  upon  his  own  ingenuity  to  devise  fermented  drinks  from  every 
available  substance.  Thus,  the  Tartar  ferments  milk  into  koumiss, 
the  Mexican  ferments  the  Maguey  (Agave  Americana)  into  pulque, 
the  Central  African  ferments  a  wine  from  the  palm,  the  Apache  of 
southern  Arizona  ferments  a  cactus  into  the  intoxicating  mescal,  the 
Kamtchatkan  ferments  a  peculiar  drink  from  a  poisonous  fungus, 
and  honey,  rice,  corn,  barley,  rye,  grapes,  dates  —  in  fact,  nearly 
every  cereal  and  every  fruit  —  is  in  some  part  of  the  world  made  to 
yield  the  cup  that  cheers,  and  too  often  inebriates  as  well. 

It  is  true  that  there  are  those  who  find  it  possible  to  live  without 
ever  tasting  even  the  mildest  stimulants  of  any  kind,  and  there  are 
sects  of  men,  like  the  Mohammedans  and  Buddhists,  to  whom  the 
use  of  alcohol  in  every  form  is  absolutely  forbidden  by  their  religion; 
but  most  of  them  discover  other  means  of  satisfying  an  instinctive 
craving  for  occasional  stimulation,  and  ready  substitutes  for  the 
prohibited  intoxicants  are  found  close  at  hand  in  hasheesh,  opium, 
excessive  tea  consumption,  etc.  The  economic  and  social  aspects  of 

241 


242  STIMULANTS,   BEVERAGES,   CONDIMENTS 

this  subject  alone  are  of  vast  importance,  and  the  question  of  the 
utility  of  stimulants  and  beverages  is  an  important  branch  of  dietetics. 

The  effects  of  all  beverages  and  stimulants  are  far  more  pro- 
nounced if  they  be  taken  into  an  empty  stomach,  which  insures  their 
prompt  absorption. 

The  several  substances  classed  under  these  headings  are  found  to 
serve  in  one  or  more  of  the  following  ways : 

I.  To  relieve  excessive  thirst  all  fluids  which  are  not  too  sweet  may 
be  used,  but  sour  beverages,  such  as  acid  lemonade  or  raspberry  vine- 
gar, the  effervescing  carbonated  waters,  solutions  of  potassium  bitar- 
trate,  or  dilute  mineral  acids  in  water,  are  generally  the  most  accept- 
able. 

II.  As  diuretics  the  mineral  waters  and  carbonated  waters  hold 
the  first  rank.     With  many  persons  coffee  is  also  an  active  diuretic. 
So  are  beer,  gin,  champagne,  and,  to  a  lesser  degree,  other  forms  of 
alcohol,  and  tea. 

III.  As  diaphoretics,  hot  spirits  and  water,  hot  lemonade  or  hot  tea 
may  be  used. 

IV.  As  diluents  of  the  ingested  food  and  of  the  waste  material  of 
the  body  the  alkaline  and  carbonated  effervescing  or  bland  spring 
waters  are  the  best. 

V.  As  stimulants  of  the  nerves  and  other  organs,  the  milder  forms 
of  alcoholic  beverages,  diluted  spirits,  tea,  and  coffee  are  used. 

YI.  As  intoxicants,  beers,  ales,  strong  wines,  champagne,  strong 
liquors  and  cordials  are  the  most  powerful  agents. 

VII.  As  demulcents,  mucilaginous,  farinaceous,  and  gelatinous 
beverages  are  used  for  fevers,  etc.  Such  are  decoctions  of  Iceland 
moss  (cetraria)  or  Irish  moss,  barley  or  oatmeal  water,  arrowroot  and 
other  light  gruels,  solutions  of  gelatin,  flaxseed  tea,  etc.  When  taken 
hot  they  are  soothing  for  coughs  and  promote  expectoration. 

Till.  As  tonics  and  to  aid  digestion  may  be  mentioned  koumyss 
and  similar  fermented  milks,  malt  extracts,  ales,  light  wines,  clarets, 
Burgundies,  diluted  brandy  or  whisky,  chalybeate  and  arsenical  wa- 
ters, and  alkaline  waters  drunk  before  meals. 

IX.  As  astringents,  red  wines  and  tea  are  of  chief  importance. 

X.  For  nutrition,  cocoa,  chocolate,  fermented  milks,  such  as  kou- 
myss, etc.,  malt  extracts,  "grape  food,"  and,  because  of  the  milk  or 
cream  added,  tea  and  coffee. 

Stimulants  have  two  separate  actions:  First,  a  prompt  exhilarat- 
ing effect  or  exaltation  of  the  nervous  system,  which  endures  for  a 
few  hours,  and,  secondly,  a  period  of  depression  which  usually  bears 
a  more  or  loss  definite  relation  to  the  degree  of  previous  excitation. 


STIMULANTS   AND   BEVERAGES  243 

The  second  period  is  sometimes  longer  or  more  intense  than  the  first, 
producing  an  actual  balance  of  loss  of  vitality  in  the  system. 

Various  dietetic  drinks  have  been  advocated  for  their  supposed 
specific  action  in  stimulating  a  torpid  liver  and  as  laxatives  or  as 
diuretics ;  such,  for  example,  are  various  "  herb  teas,"  etc.,  but  they 
are  of  uncertain  efficacy. 

Many  fruit  essences  and  sirups  are  offered  for  sale  for  use  in  mak- 
ing cooling  drinks  and  invalid's  beverages.  When  thoroughly  reliable 
preparations  are  obtained  they  are  of  good  service,  but  many  of  them 
are  adulterated.  For  example,  for  lemonade,  mixtures  of  malic, 
citric,  and  tartaric  acids  are  often  substituted.  As  a  rule,  it  is  better 
to  extract  the  juice  from  the  fresh  fruit,  and  unless  large  quantities 
are  required,  this  is  almost  as  cheap.  Unfermented  California  grape 
juice  may  be  had  in  very  pure  condition,  and  it  constitutes  an  excel- 
lent beverage  for  invalids,  being  wholly  free  from  alcohol.  "  Grape 
food  "  serves  a  similar  purpose  (p.  220). 

The  preparations  under  consideration  may  be  diluted  with  ice  water, 
or  with  any  one  of  the  simple  effervescing  waters,  such  as  carbonic- 
acid  water,  Vichy,  Seltzer,  Apollinaris,  etc. 

Of  all  these  beverages,  lemonade  and  orangeade  are  perhaps  the 
most  useful  in  the  sick-room.  These  are  agreeable,  cooling,  and 
refreshing  in  fevers,  mildly  diuretic,  and  beneficial  in  many  ways. 
A  very  wholesome  drink  is  made  by  putting  the  juice  of  two  lemons 
with  three  or  four  lumps  of  sugar  into  a  tumbler  of  iced  Vichy, 
Seltzer,  or  Apollinaris,  and  stirring  in  a  saltspoonful  of  bicarbonate 
of  sodium;  to  be  drunk  while  effervescing.  The  various  fruit 
<l  shrubs  "  or  juices  have  been  mentioned  on  page  222. 

Boot  beer,  sarsaparilla,  and  ginger  ale  are  wholesome  beverages 
when  pure,  which  are  often  classed  as  "  soft  drinks."  Ginger  ale  is 
likely  to  cause  colic  unless  a  reliable  article  is  obtained  from  a  trust- 
worthy dealer.  It  makes  a  useful  "  long  drink  "  for  alcoholic  subjects 
who  are  attempting  to  recover  from  a  debauch.  They  crave  some 
beverage  which  has  life  and  sparkle,  and  the  ginger  itself  is  helpful 
to  the  stomach. 

Alkaline  and  Mineral  Waters  —  Effervescing  Waters 

There  are  many  spring  waters  used  as  beverages  and  drunk  either 
with  or  between  meals.  They  possess,  in  addition  to  the  properties 
of  plain  water,  a  mildly  tonic  effect  upon  the  mucous  membrane  of 
the  stomach,  due  either  to  the  carbon-dioxide  gas  or  salts,  or  both, 
which  they  may  contain,  and,  owing  to  their  salts  and  water,  they  are 
also  diuretic.  Many  of  these  waters  are  sold  "  plain  " —  i.  e.,  without 


244  STIMULANTS,   BEVERAGES,   CONDIMENTS 

free  gas,  and  others  either  hold  natural  C02  or  are  made  "  sparkling  " 
by  having  this  gas  pumped  into  them  under  pressure. 

These  waters  are  very  useful,  when  taken  half  an  hour  before  meals, 
to  cleanse  the  mucous  membrane  of  the  stomach  and  prepare  it  for 
the  reception  of  food.  They  also  serve  to  dilute  and  wash  out  waste 
materials  from  the  system  through  the  kidneys. 

The  effervescing  or  carbonic-acid  waters  are  more  highly  charged 
with  gas  as  sold  from  "  fountains  "  at  the  druggists'  or  in  siphons 
than  when  bottled. 

Fruit  sirups  are  combined  in  many  ways  with  soda,  carbonic-acid, 
or  other  effervescing  waters,  to  make  soda  water  and  similar  beverages. 
That  distinctively  American  summer  beverage,  ice-cream  soda,  consists 
of  fruit  sirup  and  soda  water  to  which  ice  cream  is  added.  The  flavor 
is  usually  varied  through  the  sirup  rather  than  the  ice  cream.  Under 
proper  conditions  it  is  a  wholesome  and  nutritious  concoction,  but 
it  may  "  disagree "  from  being  drunk  when  one  is  overheated 
or  exhausted,  drunk  at  the  wrong  time  in  relation  to  meals,  or 
made  too  sweet,  or  with  spoiled  cream,  the  bad  taste  of  which  is  dis- 
guised. 

Ginger  ale,  sarsaparilla,  etc.,  are  made  effervescing,  and  are  often 
used  as  cooling  and  refreshing  drinks. 

The  habit  which  some  persons  form  of  drinking  large  quantities  of 
alkaline  waters  independent  of  any  special  needs  of  the  system  should 
be  condemned.  It  leads  to  the  condition  which  Trousseau  long  ago 
described  as  "mineral-water  cachexia."  All  the  effervescing  waters 
when  taken  in  excess  are  apt  to  excite  or  increase  flatulency  and  give 
rise  eventually  to  dyspepsia  and  debility,  with  sometimes  dilatation  of 
the  stomach,  especially  when  combined  with  sweet  sirups.  They 
should  be  avoided  in  dilatation  of  the  stomach,  flatulent  dyspepsia,  and 
palpitation. 

Some  waters  are  drunk  for  their  laxative  or  purgative  action,  and 
others  for  the  salts  which  they  contain,  like  those  of  sulphur,  iron,  or 
arsenic.  This  leads  to  the  classification  of  mineral  waters  into  alka- 
line, saline,  chalybeate,  sulphurous,  acidulous,  arsenical,  etc. 

Thermal  waters  are  those  which  issue  hot  from  their  springs.  Many 
persons  believe  that  these  waters  possess  special  properties  by  virtue 
of  being  hot,  which  they  lose  as  the  heat  departs,  but  there  is  no 
physiological  ground  for  this  belief. 

Many  tnblc  waters,  like  Poland  water  (a  plain  carbonic-acid  water), 
Yiehy,  Johannis,  Apollinaris,  and  Seltzer  (effervescing  carbonic-acid 
waters),  are  used  mainly  as  an  agreeable  table  beverage,  and  to  dilute 
spirits,  wines,  lemonade,  etc.  They  are  cooling,  refreshing,  and  whole- 


STIMULANTS   AND   BEVERAGES  245 

some.  Patients  will  often  drink  fluid  of  this  kind  who  are  not  willing 
to  drink  sufficient  ordinary  water. 

Johannis  water  is  an  alkaline  carbonated  water  which  comes  from 
a  spring  at  Zollhaus,  in  the  Taunus  Mountains.  It  contains  prin- 
cipally carbonates  of  lime,  soda,  and  magnesia,  besides  traces  of  other 
materials,  and  considerable  free  carbonic-acid  gas. 

A  glass  of  Apollinaris  or  similar  water  taken  an  hour  after  a  too 
heavy  dinner  promotes  digestion  and  helps  remove  waste  products  from 
the  system.  In  fevers  such  waters  are  always  useful,  and  they  may  be 
given  very  freely.  They  often  allay  nausea  and  vomiting.  They  may 
be  employed  for  the  dilution  of  liquors  and  milk  or  cream  for  invalids. 
Some  persons  can  digest  milk  better  when  diluted  with  Vichy,  car- 
bonic-acid water,  plain  soda  water,  or  Seltzer.  The  addition  of  the 
latter  tends  to  overcome  the  constipation  which  milk  is  liable  to  cause. 

Some  waters  are  sold  as  natural  lithia  waters,  but  the  quantity  of 
lithium  contained  in  any  spring  water  is  usually  very  minute,  and 
beverages  of  this  class  are  generally  reinforced  artificially  by  lithium 
salts.  They  are  used  to  counteract  the  lithic-acid  diathesis,  gout,  and 
rheumatism. 

Kronenquelle  water  is  an  alkaline  lithia  water  from  Obersalzbrunn, 
in  Silesia,  which  contains  considerable  sodium  carbonate  and  traces  of 
iron  and  manganese. 

The  Buffalo,  Londonderry  (New  Hampshire),  and  other  lithia  wa- 
ters are  much  prescribed  in  this  country. 

Below  is  given  a  list  of  a  few  of  the  more  noted  waters  which  are 
extensively  used  in  conjunction  with  dietetic  treatment,  both  at  the 
natural  springs  and  in  bottled  form. 

1.  Alkaline  Waters. —  Celestins  Vichy,  in  France;  Ems  and 
Fachingen,  in  Germany;  Saratoga  Vichy  (rich  in  C02),  New  York; 
St.  Louis  Springs,  Michigan  (poor  in  C02)  ;  Bethesda  Springs,  Wis- 
consin. 

Other  sodium  chloride  waters,  containing  also  carbonates  and  C02, 
are  those  of  Hathorn  Spring,  Congress  Spring,  and  Kissengen  Spring, 
in  Saratoga,  New  York;  Homburg,  Wiesbaden,  Kissengen,  and  Selt- 
zers, in  Germany;  Bourbonne,  in  France. 

The  alkaline  waters  all  contain  more  or  less  carbon  dioxide,  and 
their  most  important  ingredients  are  the  alkaline  carbonates. 

They  also  contain  sodium  chloride,  and  sometimes  sodium  sulphate. 
Some  have  one  variety  of  salts,  some  another,  which  preponderates. 
Generally  speaking,  the  European  waters  are  richer  in  alkalies  than 
are  the  American. 

Alkaline  waters  are  useful  in  the  uric-acid  diathesis  and  lithoemic 


246  STIMULANTS,   BEVERAGES,   CONDIMENTS 

conditions,  gout,  chronic  rheumatism,  obesity,  hepatic  engorgement, 
gallstones,  hyperacidity  of  the  gastric  juice,  chronic  gastric  ulcer, 
and  catarrhs  of  the  mucous  membranes,  especially  of  the  stomach, 
respiratory  tract,  and  bladder. 

2.  Alkaline  Sulphur  Waters. —  Richfield  Springs,  Sharon  Springs, 
Avon  Springs,  in  New  York;  Greenbrier  White   Sulphur   Springs, 
in  West  Virginia ;  Harrogate,  in  England ;  Neuendorf,  Meinberg,  and 
Aix-la-Chappelle,  in  Germany. 

These  waters,  containing  sulphuretted  hydrogen  in  addition  to 
other  ingredients,  are  much  used  in  gout,  chronic  rheumatism,  obesity, 
and  chronic  eczema.  They  are  often  supplemented  by  a  course  of 
chalybeate  waters. 

Hot  sulphur  springs  are  found  at  the  Hot  Sulphur  Springs  of 
Arkansas  and  Virginia,  Schlangenbad  in  Germany  and  Plombieres. 
in  France. 

3.  Alkaline  and  saline  purges  contain  a  high  percentage  of  sodium 
and  magnesium   sulphates.     These  waters  are  often   called  "bitter 
waters." 

Such  are:  Piillna,  in  Bohemia  (the  strongest  of  all,  and  one  of 
the  oldest  known)  ;  Carlsbad  (Sprudel)  and  Marienbad  (Kreuz- 
brunnen),  in  Bohemia;  Friedrichshall,  in  Germany;  Franz  Josef,  in 
Austria ;  Kissengen  Bitterwater,  in  BaATaria ;  Hunyadi  Janos,  and 
Apenta,  in  Hungary;  Eubinat  Condal  Spring  and  Villacabras,  in 
Spain;  Epsom,  in  England;  Crab  Orchard,  Estill  Springs,  in  Ken- 
tucky; Bedford  Springs,  in  Pennsylvania;  some  of  the  Saratoga 
waters,  and  Mount  Clement  Spring,  in  Michigan,  which  latter  water 
contains  iron. 

These  waters  are  useful  to  counteract  indiscretions  in  diet  and 
the  overloading  of  the  liver. 

Rtibinat  and  Apenta  waters  are  effective  and  possess  the  advantage 
of  being  less  disagreeable  than  many  of  the  others. 

Villacabras  water  is  a  Spanish  sodium  sulphate,  strongly  purga- 
tive water,  obtained  not  far  from  Madrid. 

These  waters  should  be  taken  either  very  cold  or  in  a  half-pint 
of  very  hot  water.  If  drunk  lukewarm  their  taste  is  nauseous,  and 
may  excite  emesis.  The  dose  varies  from  two  to  six  or  eight  ounces. 

4.  Chalybeate   Waters. —  Schwalbach    (Stahlbrunnen),    Germany; 
Pyrmont  (Xeubrunnen)  Spa,  Belgium;  St.  Moritz,  Switzerland;  Rock 
Enon.   Virginia.     These   waters   serve   as   tonics   for  the   blood   and 
nerves,  but  if  too  long  used  they  cause  dyspepsia  and  amemia. 

r>.  Acidulous  waters  contain  C02  in  excess,  but  little  salts  of 
any  kind.  Such  are  the  waters  of  Clysmic  Spring,  in  Wisconsin; 


STIMULANTS   AND   BEVERAGES 


Blue  Lick,  in  Kentucky;  Carlsbad  (Dorotheenquelle),  in  Bohemia. 
6.  Various  waters  are  the  Alum  Springs,  in  Virginia;  Oak 
Orchard  Acid  Spring,  in  New  York;  Bourboule,  in  France,  which 
contains  arsenic.  Eoncegno  water  is  a  ferruginous  arsenical  water 
from  the  Tyrolean  Province  of  Trent.  The  springs  of  Baden  Baden 
are  also  of  this  nature. 

Tannin 

Tannin  is  an  astringent  of  vegetable  origin  which  exists  in  tea, 
coffee,  and  many  wines,  especially  the  red  wines,  and  as  such  it  is 
worthy  of  brief  separate  consideration.  It  possesses  no  nutrient 
power  whatever,  and  is  mainly  of  interest  to  the  dietetist  from  the 
harm  it  may  occasion  if  taken  too  freely.  In  strong  solution  it 
precipitates  the  ferment  of  the  gastric  juice  and  renders  it  inert, 
and  also  gives  rise  to  constipation  by  its  astringency,  which  affects 
the  mucous  membrane  of  the  intestine.  For  these  reasons  strong 
tea  or  tea  drunk  to  excess  materially  hinders  gastric  digestion. 

According  to  Fraser,  the  tannin  in  tea  interferes  with  the  diges- 
tion of  fresh  meat,  but  to  a  less  extent  with  that  of  dried  or  smoked 
meat,  such  as  tongue  or  ham,  the  fibers  of  which  are  already  shrunken 
by  curing.  Coffee  contains  much  less  tannin  than  tea,  thus  it  has 
not  the  same  effect  upon  the  alimentary  canal;  in  fact,  it  may  be 
laxative. 

Tannin  is  contained  in  red  wines  in 
considerable  quantity,  hence  clarets  are 
mildly  astringent  and  constipating. 

Tannin  is  useful  for  a  variety  of  local 
astringent  applications. 

Tea 

Method  of  Preparation. —  Tea  is  a  prep- 
aration made  from  the  leaves  of  various 
species  of  a  hardy  evergreen  shrub  called 
Thea.  (Fig.  41.)  The  manufacture  con- 
sists in  plucking  the  young  leaves  of  the 
plant  and  placing  them  in  the  sun;  after 
they  have  become  withered  they  are  rolled 
and  twisted.  This  process  is  sometimes 
conducted  by  hand,  or  even  by  the  feet  of 
the  natives  in  China,  and  sometimes  by  FIG.  41. —  BRANCHES  OF  TEA 

machinery.     The   leaves   are  next   passed  *a)  bud>   *b)  flower- 

.    ,  1%  n    j    •    j.  -,        (U.   S.  Dept.  of  Agri.,   Bui. 

into  small  masses  or  rolled  into  balls  and  56.) 


248  STIMULANTS,   BEVERAGES,   CONDIMENTS 

allowed  to  ferment  while  still  moist,  after  which  they  are  dried  over 
a  fire  of  a  temperature  sufficient  to  evaporate  all  the  moisture.  They 
are  finally  sifted  and  assorted  into  different  qualities. 

Green  and  Black  Tea. —  The  distinction  between  black  and  green 
teas  is  due  to  the  variations  in  their  mode  of  preparation,  and  not 
to  separate  species  of  the  plant.  Green  tea  is  made  by  steaming 
the  leaves  before  they  are  rolled  and  dried.  The  further  difference 
between  green  and  black  tea  consists  in  the  relatively  larger  quan- 
tity of  astringent  material  (tannin)  which  predominates  in  green 
tea.  The  following  table,  from  an  analysis  by  Mr.  Y.  Kozai,  illus- 
trates this  point  and  exhibits  the  proportionate  quantity  of  some  of 
the  more  important  ingredients  of  tea.  It  presents  the  difference 
in  percentage  composition  between  green  and  black  tea  prepared 
from  the  same  plant : 


Green  tea. 

Black  tea. 

Crude    protein      

37.43 

38  90 

Fiber     

10.06 

10  07 

Ash     

4.92 

4.93 

Theine    

3.20 

3.30 

Tannin                                         .  .        

10  64 

4  89 

Total  nitrogen        

5.99 

6  22 

•Because  green  tea  contains  more  than  twice  as  much  of  the  as- 
tringent tannin  as  black  tea  it  is  generally  regarded  as  less  whole- 
some than  the  latter.  It  is  also  believed  to  have  a  somewhat  less 
stimulating  effect  upon  the  nervous  system,  though  this  hardly  can 
be  accounted  for  by  the  slight  variation  in  the  percentage  of  theine 
shown  to  exist  by  the  above  table,  this  latter  substance  being  the 
alkaloid,  which  is  chiefly  responsible  for  the  stimulating  influence  of 
tea  upon  the  nerves. 

There  has  been  some  discussion  in  regard  to  the  identity  of  theine 
with  caffeine,  and  by  many  writers  they  are  believed  to  be  the  same 
alkaloid.  Rice  says  that  most  of  the  commercial  caffeine  is  derived 
from  tea  leaves,  but  May  finds  that  in  frogs,  at  least,  "theine  pro- 
duces spontaneous  spasms  and  convulsions,  while  caffeine  does  not. 
Theine  impairs  the  nasal  reflex  early  in  the  poisoning  process,  while 
caffeine  does  not,  if  at  all,  until  the  very  last  stage." 

Properties. —  The  peculiar  stimulating  properties  which  tea  pos- 
sesses, as  well  as  its  color  and  agreeable  flavor,  depend  upon  the 
season  of  the  year  at  which  the  leaves  are  gathered,  the  variety  of 
the  plant,  the  age  of  the  leaves,  which  naturally  become  tough  as 


STIMULANTS   AND   BEVERAGES  249 

they  grow  older,  and  the  care  exercised  in  their  preparation.  The 
flavor  is  produced  by  the  formation  of  volatile  oils  which  develop 
during  fermentation.  It  is  these  substances  which  cause  the  minor 
differences  in  effect  of  tea  and  coffee. 

The  aroma  as  well  as  the  flavor  of  tea  is  often  artificially  in- 
creased by  the  addition  of  such  substances  as  the  leaves  of  orange 
flowers,  jasmine,  or  roses. 

Tea  made  of  small  leaves  packs  closely,  and  if  measured  by  the 
spoonful  gives  a  stronger  beverage  than  the  coarser-grained  varieties. 

Infusion. —  The  flavor  of  tea  depends  not  only  on  the  character 
and  fermentation  of  the  leaves,  but  upon  that  of  the  water  which  is 
added  to  them.  About  a  drachm  of  leaves  should  be  used  for  one 
infusion.  The  water  should  be  poured  upon  the  tea  leaves  when 
boiling,  and  the  infusion  should  not  last  beyond  three  or  four  minutes 
if  the  flavor  is  to  be  delicate;  if  it  is  continued  beyond  this  point 
materials  become  extracted  from  the  leaves  which,  while  they  may 
make  the  tea  appear  stronger,  materially  diminish  the  delicacy  of  its 
flavor.  The  water  should  be  neither  too  hard  nor  too  soft.  Soft 
water  extracts  more  of  the  soluble  materials  of  the  leaves  and  yields 
a  beverage  of  darker  color.  Water  which  contains  iron  or  lime  salts 
should  be  boiled  with  sodium  carbonate  before  it  is  used  for  tea 
infusion. 

Physiological  and  Therapeutic  Action. —  Good.  Effects. —  Tea  is 
mildly  stimulating  to  the  nervous  system  and  tends  to  increase  the 
activity  of  certain  vital  functions.  It  is  refreshing  and  relieves  bodily 
fatigue.  For  the  latter  purpose  it  has  been  found  especially  useful 
for  soldiers  on  the  march  in  hot  climates. 

Major  Woodruff,  U.  S.  A.,  says :  "  The  universal  experience  of 
military  men  testifies  to  the  absolute  necessity  of  tea  or  coffee.  The 
latter  is  generally  preferred,  but  the  writer's  experience  points  to 
tea  as  preferable  in  the  long  run."  For  this  purpose  both  these 
substances  are  better  preserved  if  compressed  into  small  bulk. 

In  persons  having  nervous  exhaustion  a  cup  of  hot  tea  affords 
prompt  and  decided  relief  from  headache,  and  when  taken  quite 
strong  it  is  sometimes  serviceable  in  the  cure  of  chronic  alcoholism. 
It  is  also  used  as  an  antidote  for  opium  poisoning,  but  coffee  is 
preferable. 

The  "  strength  "  of  tea  as  applied  to  the  appreciation  of  its  taste 
in  distinction  from  its  effect  on  the  nerves  is  due  to  the  quantity  of 
tannin  present,  which  is  bitter.  A  bitter  tea  is  not  therefore  neces- 
sarily a  strong  one  in  its  stimulating  properties,  which  are  owed  to 
the  theine. 


250 


STIMULANTS,   BEVERAGES,   CONDIMENTS 


Tea,  when  employed  as  a  beverage,  possesses  some  effects  which 
are  not  strictly  due  to  action  upon  the  nerves.  It  introduces  con- 
siderable hot  water  into  the  system,  which  is  beneficial  when  taken  at 
the  proper  time  in  relation  to  meals,  and  when  milk  or  cream  and 
sugar  are  added  its  nutritive  value  becomes  appreciable.  Tea  is 
moderately  sudorific  in  action,  and  it  has  a  slight  influence  in  regulat- 
ing the  circulation  and  temperature  of  the  body,  which,  if  too  cold, 
becomes  warm  by  the  stimulating  effect  upon  the  heart,  whereas  if 
the  body  is  too  hot,  tea  may  exert  a  cooling  influence  by  increasing 
perspiration  and  evaporation  from  the  surface.  Hot  tea  will  some- 
times increase  the  action  of  aperients,  but  it  is  doubtful  whether  it 
has  any  more  effect  than  a  similar  quantity  of  hot  water. 

Roberts  gives  the  following  analysis  of 

The  Effects  of  Tea  and  Coffee  on  Gastric  Digestion. 

Digesting  mixture:  2  grams  of  dried  beef  fiber,  0.15  c.  c.  hydrochloric  acid, 
1  c.  c.  glycerin  extract  of  pepsin,  varying  proportions  of  tea  and  coffee, 
water  to  100  c.  c. 


PROPORTION  OF  TEA  OR 
COFFEE  CONTAINED  IN  THE 
DIGESTING  MIXTURE. 

TIME  IN  WHICH  DIGESTION  WAS  COMPLETED. 
(NORMAL,  100  MINUTES.) 

Tea,  5-per-cent 
strength. 

Coffee,  5-per-cent 
strength. 

Coflee,  i5-per-cent 
strength. 

10  per  cent  

105  minutes. 
140 
180          " 
Embarrassed. 

105  minutes. 
140 
180 
Embarrassed. 

160  minutes. 
Embarrassed. 
Almost  no  action 

20     "       "            

40     "       "          

60     "      "         

Many  elderly  people  find  tea  particularly  satisfying  and  soothing 
after  reaching  a  period  of  life  when  the  functional  activity  of  the 
stomach  is  gradually  weakened.  A  disproportion  may  exist  between 
the  quantity  of  food  which  the  stomach  can  digest  and  the  actual 
need  of  the  body  for  nutritive  materials  to  counterbalance  the  daily 
waste.  In  such  cases  tea  enables  the  aged  poor  to  live  on  less  food 
than  they  would  otherwise  require,  and  is  thus  economical  for  them. 

The  refreshing  effect  of  tea  when  taken  into  an  empty  stomach 
after  bodily  fatigue  may  continue  between  three  and  four  hours,  a 
period  considerably  longer  than  that  of  coffee  or  light  wine. 

///  Effects. —  The  ill  effects  of  excessive  tea  drinking  —  the  "  tea 
habit "  —  are  referable  to  its  action  on  the  digestive  and  nervous 
systems  and  are  cumulative.  If  taken  in  large  quantities  with  meals, 
tea  precipitates  the  digestive  ferments,  retards  the  activity  of  diges- 
tion, and  may  occasion  gastric  irritation  and  catarrh.  Constipation 
usually  results,  though  there  is  sometimes  diarrhoea,  and  more  or 


STIMULANTS   AND   BEVEKAGES  251 

less  flatulency.  The  latter  may  cause  insomnia.  The  effect  of  the 
"tea  habit"  on  the  nervous  system  is  to  overstimulate  and  then 
depress  it,  first  producing  restlessness,  worry,  and  insomnia,  and 
finally  muscular  tremors,  sensory  disturbances,  and  palpitation.  Per- 
sons who  are  subjected  to  some  unusual  strain  or  anxiety  may  find 
that  tea  for  the  time  being  disagrees  with  them,  whereas  they  are 
able  to  drink  it  regularly  when  in  ordinary  health.  Cheap  teas  are 
always  much  more  liable  to  produce  ill  effects  than  the  more  expensive 
varieties.  In  many  persons  five  cups  of  strong  tea  per  diem  pro- 
duce symptoms  of  the  "tea  habit." 

Indian  teas  contain  a  larger  proportion  of  tannin  than  do  those 
from  China.  For  this  reason  they  are  more  likely  to  produce  disor- 
ders of  digestion  and  constipation.  They  also  occasion  nervousness 
and  sleeplessness  to  a  more  marked  degree  when  drunk  in  excess. 

The  ill  effects  of  poor  tea  and  of  tea  rich  in  tannin  may  be  over- 
come in  some  degree,  as  suggested  by  Eoberts,  by  the  addition  of 
carbonate  of  sodium  in  the  proportion  of  ten  grains  to  the  ounce  of 
dried  tea  leaves ;  this  does  not  materially  interfere  with  the  taste. 

When  tea  taken  with  milk  and  sugar  is  found  to  disagree,  sub- 
stitution of  the  juice  of  a  slice  or  two  of  lemon  makes  it  acceptable 
and  beneficial  to  many  persons.  Tea  which  is  "  steeped "  is  more 
unwholesome  on  account  of  the  extra  tannin,  etc.,  which  is  extracted. 

Tea  should  be  avoided  in  dyspepsia,  gastric  irritability  from  any 
cause,  constipation,  anemia,  insomnia,  "  nervousness,"  and  gastric 
catarrh. 

A  case  of  multiple  neuritis  caused  by  drinking  between  two  and 
three  pints  daily  of  strong  tea  has  been  reported  by  Spratling,  and 
I  have  met  with  one  or  two  similar  cases. 

In  a  recent  report  upon  insanity  in  Ireland  tea  is  mentioned  as  a 
contributing  factor.  A  very  poor  quality  is  there  used,  and  it  is  often 
stewed  nearly  all  day,  water  being  added  from  time  to  time.  This 
report  continues:  "Undoubtedly  the  method  of  preparation  adopted 
and  the  excessive  use  of  this  article  of  diet,  now  so  general  among 
our  poorer  population,  tends  to  the  production  of  dyspepsia,  which 
in  its  turn  leads  to  states  of  mental  depression  highly  favorable  to 
the  production  of  various  forms  of  neurotic  disturbance."  Excep- 
tionally the  "  tea  habit "  has  been  acquired  through  chewing  the 
leaves. 

Adulteration  of  Tea. —  The  adulteration  of  tea  is  extensively  prac- 
ticed. The  adulterants  are  either  added  in  very  minute  proportion, 
as  in  the  case  of  plumbago,  indigo,  or  Prussian  blue,  for  the  purpose 
of  coloring  or  "  facing  "  the  tea,  or  foreign  leaves  are  mixed  with  the 


252 


STIMULANTS,    BEVERAGES,    CONDIMENTS 


tea,  which  merely  dilute  it  without  necessarily  making  it  injurious. 

Green  tea  is  more  likely  than  black  to  be  adulterated.     Catechu  as 

well  as  salts  of  iron  are  sometimes  added  to  increase  the  astring- 

ency. 

Quantity  Consumed. —  The  quantity  of  tea  consumed  per  capita 

in  the  United  States  is  1.33  pound;  that  of  coffee  is  7.8  pounds. 

Slightly  more  than  half  of   the  tea  drunk  in  the  United   States 

comes  from  China,  and  a  large  part  of  the  remainder  from  Japan. 

The  India  teas  are  nearly  twice  as  strong  as  the  others,  but  they 

are  much  less  drunk  in  this  country  except- 
ing in  mixtures  where  they  have  been  added 
to  Chinese  or  Japanese  teas  to  improve 
their  flavor  and  strength. 

Coffee 

Composition. —  Coffee  consists  of  the  ber- 
ries or  seeds  of  Coffea  ardbica,  which  are 
dried,  roasted,  ground,  and  subjected  to 
infusion.  The  coffee  drunk  in  the  United 
States  is  mainly  imported  from  South  and 
Central  America,  Mexico,  and  Java,  63  per 
cent  being  imported  from  Brazil.  The  Rio 
berry  is  smaller  than  that  from  Java.  The 
composition  of  coffee  beans  varies  some- 
what, but  an  approximate  idea  of  it  is 
obtained  from  the  following  table  from 
Konig,  which  gives  the  percentage  of  the 
important  ingredients: 


FIG.    42. —  BRANCHES    OP 

COFFEE. 

(a)    flower,    (b)    berry. 

(U.    S.   Dept.   Agri.,   Bui. 

56.) 


Water   1.15 

Fat    14.48 

Crude  fiber    19.89 

Ash    4.75 

Caffeine    1.24 

Albuminoids    13.98 

Other  nitrogenous  matter    45.09 

Sugar,  gum,  and  dextrin   1.66 

The  exhilarating  and  stimulating  effect  of  coffee  is  caused  by  the 
ingredients  caffeine,  caffeotannic  and  caffeic  acids,  and  a  volatile  oil 
developed  during  roasting. 

Caffeine  is  chemically  identical  with  theine  and  possesses  the  same 
physiological  properties,  its  action  being  chiefly  upon  the  nerves  and 
kidneys.  The  coffee  berry  contains  no  starch,  and  Wiley  has  shown 
that  its  principal  carbohydrate  is  cane  sugar  or  sucrose.  There  are 


STIMULANTS  AND   BEVERAGES  253 

present  also  a  substance  allied  to  dextrin  and  a  reducing  sugar.  Cof- 
fee also  contains  a  little  aromatic  oil  which  is  moderately  stimulating 
to  the  nervous  system.  It  has  less  oil  than  tea. 

Method  of  Preparation. —  The  preparation  which  the  coffee  beans 
require  consists  of  drying  them  by  roasting  at  a  temperature  of 
fully  200°  C.,  after  which  they  are  ground  into  small  fragments  to 
facilitate  the  solution  of  their  ingredients  by  hot  water.  The  heat 
converts  the  sugar  of  the  beans  into  caramel  and  develops  volatile 
and  aromatic  substances  to  which  the  agreeable  aroma  of  the  cof- 
fee is  due.  These  substances  being  volatile,  the  aroma  soon  for- 
sakes the  beans,  and  they  should  not  be  roasted  or  ground  long 
before  they  are  to  be  used.  The  roasting  also  liberates  gases  in  the 
beans,  which  cause  them  to  increase  in  bulk  while  losing  in  weight. 

The  methods  of  preparing  coffee  as  a  beverage  are  three: 

(1)  In   filtration   boiling   water    is    allowed   to    percolate   slowly 
through  finely  ground  coffee.     Air  should  be  excluded  as  much  as 
possible  during  the  process;  otherwise  the  oxygen  alters  the  aroma. 
According  to  von  Liebig,  filtration  only  dissolves  from  11  to  15  per 
cent  of  the  coffee  instead  of  20  or  21  per  cent,  which  is  obtainable 
by  other  means. 

(2)  Infusion  is  the  common  mode  of  preparation  of  coffee  em- 
ployed in  this  country  and  in  Europe.     It  is  said  to  reduce  the  ex- 
citing  influence   of   strong  coffee   without   destroying   its   aroma   or 
otherwise  altering  it.     In  conducting  this  process  the  finely  ground 
coffee   is  put  into   water   previously  boiled,   but   removed   from  the 
fire,  and  allowed  to  stand  for  about  ten  minutes  at  a  temperature  of 
180°  or  190°  F.     - 

(3)  Decoction  is  the  method  principally  used  in  Turkey  and  else- 
where in  the   East.     The  coffee  beans  are  ground  to  powder   and 
placed  in  cold  water,  which  is  then  heated  to  boiling.     The  beverage 
is  drunk  without  straining.     If  boiled  a  few  minutes  some  aroma 
still  remains,  but  it  is  soon  driven  off,  and  continued  boiling  extracts 
more  caffeine  and  tannin  than  is  obtainable  by  infusion. 

Soft  water  extracts  more  coffee  from  the  berries  than  hard,  as 
it  does  from  tea  leaves. 

Coffee  should  always  be  made  from  newly  roasted  and  ground 
beans;  and  when  economy  is  to  be  considered,  or  when  strength  and 
aroma  are  both  desired,  a  larger  proportion  of  the  soluble  ingredients 
may  be  obtained  by  combining  the  second  and  third  processes,  as 
described  by  Yeo :  "  After  first  preparing  an  infusion  by  passing 
boiling  water  over  the  coffee,  the  grounds  left  should  be  boiled  in 
more  water,  and  the  boiling  decoction  thus  obtained  should  be  poured 


254  STIMULANTS,   BEVERAGES,   CONDIMENTS 

over  another  portion  of  freshly  ground  coffee;  this,  in  turn,  is  also 
boiled  with  more  water,  to  be  used  again  with  fresh  coffee  in  the 
same  manner,  and  so  on.  By  this  method  all  the  soluble  matters  in 
the  coffee  are  extracted  and  none  of  the  aroma  is  needlessly  dis- 
sipated/' Eeady-made  coffee  is  sometimes  preserved  with  condensed 
milk  and  sugar  in  tin  cans.  This  preparation  merely  requires  to 
be  put  into  a  cup  of  hot  water  to  be  fit  for  drinking. 

Physiological  Action. —  Good  Effects. —  Coffee,  when  taken  as  a 
beverage,  has  well-marked  physiological  effects,  chiefly  upon  the  mus- 
cular, vascular,  and  nervous  systems.  It  removes  the  sensation  of 
fatigue  in  the  muscles  and  increases  their  functional  activity ;  it  allays 
hunger  to  a  limited  extent;  it  strengthens  the  heart  action,  and  con- 
stitutes a  valuable  cardiac  stimulant  in  some  forms  of  collapse  by 
its  moderate  quickening  effect  upon  the  pulse  and  influence  upon  the 
vascular  tone;  it  acts  as  a  diuretic,  and  increases  the  excretion  of 
urea ;  it  has  a  mildly  sudorific  influence ;  it  counteracts  nervous  ex- 
haustion and  stimulates  nerve  centers.  It  is  used  sometimes  as  a 
nervine  in  cases  of  migraine,  and  there  are  many  persons  who  can 
sustain  prolonged  mental  fatigue  and  strain  from  anxiety  and  worry 
much  better  by  the  use  of  strong  black  coffee.  In  low  delirium,  or 
when  the  nervous  system  is  overcome  by  the  use  of  narcotics  as  in  the 
case  of  opium  poisoning,  or  by  alcohol,  or  by  excessive  hemorrhage, 
strong  black  coffee  is  serviceable  to  keep  the  patient  from  falling 
into  the  drowsiness  which  soon  merges  into  coma.  In  such  cases  as 
much  as  half  a  pint  of  strong  black  coffee  may  be  injected  into  the 
rectum. 

Drunk  in  moderation,  coffee  is  a  mild  stimulant  to  gastric  diges- 
tion. In  the  bowels  coffee  has  an  opposite  effect  to  that  of  tea,  for 
it  stimulates  peristalsis,  and  for  many  people,  when  drunk  early  in 
the  morning,  it  possesses  a  distinctly  laxative  effect.  It  thus  in- 
directly benefits  the  liver.  Strong  coffee  with  a  little  lemon  juice 
or  brandy  is  often  useful  in  overcoming  a  malarial  chill  or  a  par- 
oxysm of  asthma. 

The  stimulating  and  diuretic  effect  of  coffee  is  more  decided 
when  it  is  taken  into  an  empty  stomach. 

The  nutrient  value  of  coffee  alone  is  too  slight  to  be  considered, 
but  the  addition  of  sugar  and  milk,  as  in  the  case  of  tea,  makes  it  a 
valuable  food.  It  does,  however,  possess  some  effect  in  diminishing 
tissue  waste.  The  very  general  fondness  which  exists  for  the  taste 
of  coffee  makes  it  a  useful  means  of  flavoring  many  kinds  of 
foods  for  invalids,  such  as  jellies,  custards,  ice  cream,  etc.  When  the 
taste  of  milk  is  objected  to,  the  addition  of  two  or  three  teaspoonfuls 


STIMULANTS   AND   BEVERAGES  255 

of  coffee  to  the  tumblerful  of  milk  will  often  overcome  the  dislike 
for  it. 

Coffee  is  a  useful  temporary  cardiac  stimulant  for  children  suffer- 
ing collapse,  but  should  not  be  given  them  as  a  daily  beverage. 

Caffein  is  much  used  in  medicine  as  a  cardiac  and  nerve  stimulant 
and  diuretic. 

Ill  Effects. —  Strong  black  coffee  taken  after  dinner  tends  to  re- 
tard the  digestive  processes  somewhat,  and  for  this  reason  it  should 
be  avoided  by  dyspeptics;  but  to  persons  with  sound  digestion  who, 
perhaps,  have  eaten  rather  more  food  than  they  need,  this  influence 
may  not  prove  a  disadvantage,  and  meanwhile  its  stimulating  effect 
may  arouse  the  overtaxed  digestive  functions. 

Many  persons  find  themselves  able  to  perform  much  more  active 
brain  work  by  the  stimulus  afforded  by  drinking  coffee  and  strong 
tea.  If  one  is  obliged  to  work  late  by  night  at  severe  mental  labor, 
sleepiness  may  be  avoided  by  this  means.  The  continuance  of  this 
practice,  however,  soon  results  in  forming  a  coffee  or  tea  habit,  in 
which  the  individual  becomes  a  slave  to  the  beverage  and  feels  an 
imperative  need  for  it  at  certain  hours  of  the  day,  when,  if  it  can- 
not be  obtained,  the  system  suffers  from  languor,  prostration  or  rest- 
lessness, and  craving.  Exceptionally  the  coffee  habit  takes  the  form 
of  eating  the  coffee  beans.  By  drinking  two  or  three  cups  of  strong 
black  coffee  at  every  meal  muscular  tremors  sometimes  are  developed, 
especially  in  the  hands,  with  "nervousness,"  anxiety,  dread  of  im- 
pending ill,  with  palpitation  and  feeling  of  precordial  oppression, 
bradycardia,  tinnitus  aurium,  hyperasthesia,  muscular  lassitude, 
vertigo,  heartburn,  dyspepsia,  constipation,  and  insomnia.  In  such 
cases  the  symptoms  usually  promptly  subside  on  suspending  or  re- 
stricting the  beverage;  but  if  they  have  been  continued  long,  the 
use  of  sedatives  may  be  necessary  to  control  the  ill  effects.  Extreme 
cases  suggest  the  condition  resulting  from  some  drug  habits,  and 
there  is  irritability  of  the  whole  nervous  system  and  mental  ex- 
citement. Emaciation  is  common,  and  pruritus  ani  has  been  observed 
by  Brown-Sequard.  Those  who  are  habituated  to  immoderate  tea 
or  coffee  drinking  do  well  to  stop  the  habit  abruptly  in  order  to 
observe  the  degree  of  craving  which  results  and  the  influence  which 
these  beverages  is  acquiring  over  the  system.  As  an  aid  to  break- 
ing off  the  coffee  habit,  "  postum  "  may  be  used.  It  is  composed 
of  cereals  and  has  a  flavor  which  many  find  agreeable.  The  pub- 
lished analysis  gives  13.13  per  cent  protein,  6G.11  per  cent  carbo- 
hydrates, 1.60  per  cent  fat,  besides  salts  and  water.  In  children  the 
habitual  use  of  coffee  gives  rise  to  insomnia,  night  terrors,  nervous- 


256  STIMULANTS,    BEVERAGES,    CONDIMENTS 

ness,  and  tremor.  Acute  coffee  poisoning  differs  from  the  chronic 
form  in  producing  greater  excitability,  with  tendency  to  delirium 
and  tachycardia.  Some  persons  are  so  sensitive  to  coffee  that  a  few 
teaspoonfuls  promptly  give  rise  to  toxic  symptoms. 

Quantity  Consumed. —  In  connection  with  the  comments  often  made 
in  regard  to  the  nervousness  of  temperament  which  characterizes 
many  Americans,  it  is  not  without  interest  to  note  a  fact  which 
may  stand  in  the  relation  of  either  cause  or  effect  to  this  condition  — 
namely,  that  the  people  of  the  United  States  consume  one-third  of 
the  total  coffee  produced,  or  more  than  Germany,  Austria,  Hungary, 
France,  and  the  United  Kingdom  combined.  On  the  other  hand, 
England  and  her  colonies  consume  one-half  of  the  world's  output  of 
tea,  and  the  United  States  but  one-fifth  of  it. 

Adulteration. —  The  adulteration  of  coffee,  more  particularly  when 
it  is  ground,  is  so  easily  accomplished  that  it  affords  great  tempta- 
tion to  unscrupulous  dealers.  Almost  all  ground  coffee  sold  to  the 
poor  is  adulterated,  but  the  adulterants  are  not  usually  of  a  char- 
acter to  render  them  injurious  to  health.  Chief  among  them  is 
chicory,  which  is  added  both  for  dilution  and  for  its  influence  on 
the  color  and  flavor  of  the  coffee.  This  substance,  however,  is 
actually  preferred  by  many  persons,  and,  as  it  is  in  no  wise  injurious, 
it  is  hardly  fair  to  consider  it  as  an  adulterant  when  its  admixture 
with  coffee  is  acknowledged. 

Chicory  is  prepared  from  the  root  of  the  chicory  plant,  or  wild 
endive,  which  is  roasted  and  ground.  By  roasting,  an  aroma  is  de- 
veloped, as  in  the  case  of  the  coffee  berry.  Chicory  contains  no 
caffeine,  but  it  holds  a  volatile  oil  and  a  bitter  principle.  Its  ad- 
mixture with  coffee  is  detected  by  bleaching  with  chlorinated  soda, 
which  acts  promptly  on  the  pigments  of  chicory,  but  very  slowly 
on  those  of  the  natural  coffee.  In  France,  coffee  is  frequently  flavored 
with  caramel  instead  of  chicory,  which  is  more  extensively  used  in 
England  and  the  United  States. 

Coffee  is  also  diluted  with  various  substances,  such  as  peas,  beans, 
peanuts,  dried  sweet  potatoes  parched,  and  ground  acorns,  corncobs, 
or  date  stones  are  sometimes  used. 

Imitation  coffee  beans  are  composed  of  pellets  of  roasted  wheat 
flour,  or  sometimes  wheat  flour  and  chicory,  or  sawdust.  Eye,  corn, 
and  barley  are  also  mingled  with  wheat  for  the  same  purpose. 

Fat  globules  are  present  in  impure  coffee  in  considerable  quan- 
tity. The  substitutes  for  coffee  are  easily  detected  by  the  fact  that, 
unlike  the  true  coffee  bean,  which,  unless  overroasted,  floats  after 
roasting,  they  usually  sink  to  the  bottom  of  a  glass  of  water. 


STIMULANTS  AND  BEVERAGES  257 

Coloring  matter,  like  ochre,  burnt  umber,  charcoal,  Prussian  blue, 
and  lead  chromate,  is  added  occasionally  before  the  roasting,  as  well 
as  burnt  sugar  and  sirups,  in  order  to  affect  the  appearance  and 
color  of  the  beans.  The  beans  are  sometimes  polished  in  cylinders, 
in  which  they  are  made  to  revolve  with  soapstone. 

Substitutes  for  Coffee. —  A  substitute  for  coffee  may  be  made 
from  wheat,  rye,  or  oatmeal,  to  which  butter  is  added  in  the  propor- 
tion of  one  part  to  eight  of  meal.  The  butter  is  melted  in  a  hot  iron 
frying  pan  and  the  meal  is  sprinkled  over  it  and  briskly  stirred  with- 
out burning.  Thus  prepared,  the  meal  resembles  roasted  coffee,  and 
when  half  an  ounce  is  boiled  in  a  pint  of  water  it  makes  a  beverage 
which  is  rather  agreeable  in  taste.  In  Bavaria  this  substitute  for 
coffee  is  used  largely  by  the  peasants,  and  it  is  also  supplied  in  some 
charitable  institutions  in  this  country.  Its  use  necessitates  boiling 
the  water,  which,  if  it  contains  any  impurities,  is  thus  rendered 
harmless.  There  are  several  cereal  substitutes  for  coffee  sold  in 
open  market  which  are  advertised  as  being  highly  nutritious.  A 
number  of  them  were  analyzed  for  the  United  States  Department 
of  Agriculture  (Bulletin  122)  by  C.  F.  Langworthy,  who  says  of 
them: 

"  The  average  cereal  coffee  infusion  had  the  following  percentage 
composition:  Water,  98.2;  protein,  0.2;  and  carbohydrates,  1.4,  while 
the  fuel  value  was  30  calories  per  pound.  Skim  milk,  which  is  ordi- 
narily considered  a  rather  "  thin  "  beverage,  contains  3.5  per  cent  pro- 
tein, 0.3  per  cent  fat,  5.15  per  cent  carbohydrates,  and  0.8  per  cent 
ash,  or  almost  twenty  times  as  much  food  material  as  the  average 
of  the  beverages  made  from  cereal  coffee.  If  made  according  to 
directions,  one  would  have  to  drink  4%  gallons  of  an  infusion  of 
one  of  them  which  made  an  especial  claim  to  high  nutritive  value 
in  order  to  get  as  much  food  as  is  contained  in  a  quart  of  skim 
milk." 

Mate,  called  also  Paraguay  tea,  is  manufactured  from  the  dried 
leaves  of  a  plant  resembling  holly.  It  is  a  mildly  stimulating  bever- 
age which  contains  theine,  but  it  has  no  special  dietetic  advantages 
over  tea  or  coffee. 

Postum  is  described  on  page  255. 

RELATIVE  VALUE  OF  COFFEE  AND  TEA 

Much  argument  has  been  expended  on  the  relative  digestibility 
and  usefulness  of  tea  and  coffee,  but  about  all  that  can  be  said 
definitely  in  regard  to  the  matter  is,  that  many  persons  who  can 

drink  tea  with  impunitv  are  made  nervous  and  are  kept  awake  by 
19 


258  STIMULANTS,   BEVERAGES,   CONDIMENTS 

a  similar  quantity  of  coffee,  whereas  there  are  others  who  find  that 
coffee  aids  their  digestion  while  tea  interferes  with  it,  and  that  it 
affects  them  in  every  way  more  agreeably  than  tea;  and  still  a  third 
class  cannot  take  either  tea  or  coffee  without  producing  indigestion, 
insomnia,  and  nervousness.  Speaking  generally,  coffee  is  believed 
in  the  United  States  to  be  more  digestible  and  useful  than  tea,  but 
in  other  parts  of  the  world,  especially  in  England,  China,  and  India, 
tea  is  regarded  as  more  beneficial  than  coffee.  In  equal  weight,  tea 
contains  more  than  twice  as  much  caffeine  or,  as  it  is  also  called, 
theine.  In  this  country,  however,  it  is  customary  to  use  about  50 
per  cent  more  of  coffee  than  of  tea  to  the  same  quantity  of  water. 

Coffee  is  said  to  irritate  the  mucous  membrane  of  the  stomach 
less  than  tea  when  drunk  in  very  large  quantities.  It  has  a  more 
decided  stimulant  action  than  tea  upon  both  the  force  and  frequency 
of  the  pulse. 

Cocoa 

Cocoa  and  chocolate  are  both  prepared  from  the  cocoa  bean,  or 
pulpy  seeds  of  the  exotic  cacao  tree,  Theobroma  cacao.  The  major 
portion  of  the  supply  consumed  in  the  United  States  is  derived 
from  Brazil,  the  British  West  Indies,  Ecuador,  Venezuela,  and  Dutch 
Guiana. 

The  cacao  tree  attains  a  height  varying  up  to  thirty-five  feet.  It 
blossoms  frequently  and  yields  two  crops  a  year  of  a  bright-yellow 
soft  fruit.  The  fruit,  which  bears  some  resemblance  to  a  small 
cucumber,  contains  two  or  three  dozen  colorless  seeds  embedded 
in  mucilaginous  material.  When  dried  in  the  sunlight,  the  seeds 
acquire  a  bright-yellow  or  brown  color  and  harden.  The  cocoa  starch 
grains  are  spherical. 

Preparation. —  Cocoa  may  be  either  fermented  or  unfermented. 
The  former  variety  is  dried  in  the  sun  at  once,  and  the  latter  is 
kept  for  some  time,  in  quantity,  in  a  cool,  moist  place,  while  fermen- 
tation proceeds.  The  process  of  fermentation  greatly  improves  the 
product,  for  the  natural  acidity  and  bitter  taste  of  the  seeds  suc- 
ceeds to  a  milder,  somewhat  aromatic,  and  more  agreeable  flavor. 

The  husks  of  the  cocoa  beans  are  irritant  to  the  alimentary  canal, 
and  possess  little  nutrient  material. 

The  kernels  when  finely  ground  constitute  "cocoa  nibs,"  from 
Avhich  a  decoction  is  made  by  boiling  in  water  for  about  two  hours, 
and  removing  the  insoluble  residue  by  straining  or  decanting;  but 
the  cocoa  usually  sold  in  market  is  made  by  grinding  the  kernels 
into  a  paste,  to  which  starch  or  sugar  is  added.  If  starch  has  been 


STIMULANTS  AND   BEVERAGES  259 

used,  the  cocoa  must  be  boiled  for  some  minutes,  but  if  diluted 
with  sugar  it  is  only  necessary  to  mix  it  with  boiling  water  or  milk. 

The  different  preparations  of  cocoa  are  very  numerous,  but  the 
quantity  commonly  used  fcr  making  a  single  cup  of  the  beverage  is 
a  heaping  teaspoonful  or  more. 

Composition. —  The  cocoa  beans,  after  being  husked  and  dried,  con- 
tain fat  and  theobromine,  besides  a  little  albumin,  starch,  pigment, 
and  salts. 

The  average  percentage  of  the  principal  ingredients  of  cocoa 
prepared  for  a  beverage  is  shown  in  the  following  analysis  by  Stut- 
zer  of  a  specimen  of  Holland  cocoa : 

Theobromine 1.73 

Total  nitrogenous  substances   19.88 

Fat    30.51 

Water  3.83 

Ash    8.30 

Fiber  and  non-nitrogenous  extract 37.48 

Theobromine  is  the  principal  alkaloid  of  cocoa,  and  is  almost 
identical,  both  chemically  and  in  its  physiological  effect,  with  caffeine. 

Cacao  Butter. —  The  fat,  which  is  called  cacao  butter,  is  the  nutri- 
ent ingredient  of  most  importance.  It  usually  constitutes  50  per 
cent  of  the  cocoa  bean.  It  has  an  agreeable  flavor  and  odor,  and 
may  be  kept  indefinitely  without  change.  Because  it  melts  readily 
at  low  temperatures,  it  is  quickly  dissolved  in  the  alimentary  canal, 
and  it  is  therefore  used  for  making  suppositories. 

Uses. —  Cocoa  is  not  as  digestible  as  is  generally  supposed,  because 
it  leaves  a  large  residue  of  unabsorbed  protein  and  its  relative  de- 
ficiency in  starches  and  salts  prevents  it  from  being  regarded  as 
a  "  complete  "  food.  Whatever  nutritive  power  cocoa  possesses  de- 
pends upon  its  fat  and  a  small  percentage  of  digestible  albumin.  If 
the  cocoa  is  roasted  by  too  high  a  temperature,  the  latter  is  destroyed. 

The  term  "  soluble  cocoa "  is  erroneous,  because  neither  the  fat 
nor  much  of  the  albuminous  material  is  truly  soluble,  and  if  they 
are  removed  the  food  value  of  the  cocoa  preparation  is  much  im- 
paired. These  substances  may,  however,  be  reduced  to  a  fine  state 
of  subdivision  and  held  in  suspension,  but  the  cocoa  bean  contains 
so  much  fat  that  it  cannot  be  powdered  unless  the  fat  is  partially 
removed  by  artificial  process  or  diluted  with  sugar  or  some  form  of 
starch.  The  various  powders  recommended  for  invalid  diet,  and 
which  are  sold  as  cocoa  or  broma,  under  different  proprietary  names, 
are  made  in  this  manner.  They  possess  rather  less  strength  than 
chocolate,  but,  on  the  other  hand,  because  they  contain  less  fat, 


260  STIMULANTS,   BEVERAGES,   CONDIMENTS 

they  may  be  better  borne  by  an  enfeebled  stomach.  The  Holland 
cocoa  and  other  preparations  are  made  with  the  object  of  obtain- 
ing a  digestible  cocoa  without  removal  of  the  fat,  which  for  this 
purpose  is  saponified  by  the  use  of  sodium  and  potassium  hydrate  and 
magnesia.  These  alkaline  substances,  while  they  may  be  beneficial 
in  some  forms  of  dyspepsia,  in  olher  cases  tend  to  interfere  with 
digestion  by  neutralizing  the  gastric  juice. 

Both  cocoa  and  chocolate  differ  from  tea  and  coffee  in  the  fact 
that  besides  making  an  agreeable  and  very  slightly  stimulating 
drink,  they  contain  more  food  substance.  Their  actual  use  for  this 
purpose,  however,  is  exaggerated.  Cocoa  further  differs  from  tea 
and  coffee  in  that  the  insoluble  material  is  consumed  as  well  as  the 
soluble. 

Various  cocoa  powders,  essences,  etc.,  are  sold  for  use  by  infants, 
a  teaspoonful  of  which  may  be  dissolved  in  a  half  pint  of  hot  water. 
Or  an  infusion  of  cocoa  nibs  may  be  made.  Such  preparations 
should  never  be  given  to  very  young  infants,  and,  as  a  rule,  it  is  best 
not  to  allow  their  use  before  the  completion  of  the  third  year,  but 
for  young  growing  children  after  that  age  they  afford  an  excellent 
beverage. 

After  suspension  in  hot  water  cocoa  exhibits  a  scum  of  fat  float- 
ing upon  the  surface  of  the  cup.  This  may  be  skimmed  off  on  a  piece 
of  bread  or  cracker  and  eaten  in  lieu  of  butter  —  a  practice  common 
among  the  Italians.  Cocoa,  on  account  of  its  large  percentage  of 
fat  in  comparison  with  starchy  ingredients,  forms  a  very  good  addi- 
tion to  a  vegetarian  diet. 

Adulteration. —  The  sophistication  of  cocoa  is  very  easy  of  accom- 
plishment as  well  as  profitable.  It  is  principally  done  with  sugars, 
starches,  and  fats.  Iron  salts  and  other  coloring  matters  are  often 
added.  These  adulterations  are  fraudulent,  but  not  necessarily 
harmful. 

Chocolate 

Preparation. —  Chocolate  is  manufactured  from  the  husked,  dried, 
ground,  and  fermented  cocoa  seeds,  which  are  then  roasted  and 
made  into  paste  and  compressed  into  cakes  by  moderate  pressure. 
To  increase  the  flavor  and  nutrient  power  of  the  cakes  more  or  less 
sugar  (but  at  least  50  per  cent)  is  added,  and  various  flavoring  ex- 
tracts, such  as  vanilla,  etc.,  or  spices,  are  mixed  with  the  paste  before 
compressing  it.  The  husks  of  the  seeds  are  separately  sold,  and  are 
used  for  adulteration  in  making  cheaper  varieties  of  chocolate.  They 
arc  inferior  to  the  seeds  in  all  their  properties. 


STIMULANTS  AND   BEVERAGES  261 

Uses. —  The  value  of  chocolate  as  a  concentrated  food  is  in  part 
derived  from  the  sugar  which  is  added,  but  it  is  very  nutritious. 
Tested  at  the  Austrian  army  manoeuvres,  a  chocolate  ration  was 
found  to  equal  five  times  its  weight  of  beef.  Like  cocoa,  if  pure 
and  carefully  prepared,  its  ingredients  are  easily  digested  and  ab- 
sorbed. In  cases  of  dyspepsia  and  various  gastric  disorders  it  forms 
an  agreeable  and  wholesome  drink,  and  enables  the  patient  to  take 
additional  nourishment  in  the  form  of  the  milk  and  sugar  mixed 
with  it.  It  is  also  mildly  stimulating  and  exhilarating  to  the  nerv- 
ous system  when  exhausted  through  overwork  or  worry,  and  pos- 
sesses the  advantage  over  tea  and  coffee  that  it  does  not  produce 
wakefulness. 

The  free  use  of  chocolate,  either  eaten  or  drunk  as  a  beverage, 
constituting  what  almost  might  be  called  a  "chocolate  habit," 
is  not  injurious  to  the  nervous  system  after  the  manner  of 
overindulgence  in  tea  and  coffee,  but  it  produces  more  or  less  gas- 
tric dyspepsia  on  account  of  the  large  quantity  of  sugar  which  it 
already  contains  or  which  is  added  to  it  when  drunk.  I  have  seen 
a  case  of  temporary  glycosuria  in  a  chocolate  manufacturer,  who  ate 
large  quantities  in  testing  samples. 

Chocolate  made  into  compressed  cakes  forms  a  convenient  portable 
food  that  will  keep  well  for  a  long  time,  especially  when  protected 
from  drying  by  a  coating  of  tinfoil  or  otherwise.  These  cakes  con- 
tain condensed  nutriment  which  makes  them  very  serviceable  upon 
expeditions  where  provisions  can  only  be  carried  in  limited  quantity. 
Condensed  milk  may  be  carried  to  drink  with  the  chocolate.  The 
fact  that  its  flavor  is  so  universally  liked  is  an  additional  advan- 
tage. 

The  chocolate  cakes  are  sometimes  prepared  with  meat  extract, 
or  when  dissolved  and  drunk,  meat  powder  or  raw  meat  may  be 
added  to  them  for  phthisical  patients  or  other  invalids  who  require 
concentrated  food. 

Chocolate,  when  not  too  rich  in  fat,  is  a  very  wholesome  food  for 
growing  children,  and  is  better  for  them  than  the  more  stimulating 
beverages  tea  and  coffee.  Its  agreeable  flavor  causes  it  to  be  used 
extensively  as  an  ingredient  of  starchy  foods  and  confections,  and 
also  to  disguise  the  taste  of  disagreeable  or  bitter  medicines,  such  as 
quinine.  Many  articles  of  invalid  diet,  such  as  cornstarch,  farina, 
gelatin,  etc.,  may  be  made  palatable  by  the  addition  of  chocolate, 
while  their  nutritive  qualities  are  enhanced. 

A  pint  of  milk  and  four  ounces  of  chocolate  yield  about  800  calories, 
which  is  a  fair  meal  for  an  invalid. 


262  STIMULANTS,   BEVERAGES,   CONDIMENTS 

Kola 

Composition. —  The  kola  nut  is  the  fruit  of  a  tall  tree  of  the  order 
Sterculiacece,  growing  in  the  island  of  Jamaica,  on  the  west  coast 
of  Africa,  East  India,  and  Ceylon.  It  resembles  both  coffee  and 
chocolate  in  some  of  its  properties,  and  its  uses  are  practically  the 
same.  It  contains  caffeine,  or  theine  and  theobromine,  besides  a  lit- 
tle fat,  glucose,  dextrin  and  starch,  cellulose,  albumins,  tannin,  mu- 
cilaginous material,  a  diastatic  and  a  milk-digesting  ferment,  and 
other  substances. 

Uses. —  Kola  is  believed  to  exercise  a  restraining  influence  upon 
tissue  waste.  It  is  also  mildly  stimulating  to  the  heart  and  nervous 
system,  and  is  diuretic  as  well  as  somewhat  tonic  in  its  action  on  the 
stomach.  It  is  said  to  increase  the  capacity  for  endurance  of  mus- 
cular work.  As  a  substitute  for  food  on  forced  marches  or  in  moun- 
tain climbing  it  is  said  by  those  who  have  tried  it  to  sustain  strength 
as  long  as  forty  hours,  and  to  serve  better  than  tea  or  coffee. 

Its  efficacy  has  been  repeatedly  tested  by  European  army  surgeons, 
especially  in  France  and  Switzerland,  for  troops  on  the  march,  and 
has  been  shown  to  lessen  fatigue  and  diminish  the  craving  for  both 
food  and  drink. 

Kola  made  into  an  infusion  like  coffee,  but  only  one-third  or  one- 
half  the  strength  of  the  latter,  forms  a  smooth,  rich,  dark-brown  fluid 
without  sediment  or  oily  scum.  It  is  drunk,  like  coffee  or  chocolate, 
with  milk  and  sugar,  and  has  a  not  unpleasant  flavor.  It  is  said  to  be 
well  borne  by  delicate  stomachs,  and  may  be  prescribed  in  fevers. 
In  large  doses  it  may  cause  insomnia. 

Alcohol 

Alcohol  is  a  substance  produced  by  a  process  developed  in  cer- 
tain sugar-yielding  substances  (such  as  grains,  molasses,  sugar  cane, 
etc. )  by  the  action  of  an  organized  ferment,  the  yeast  fungus  Saccha- 
romyces  cerevisice.  The  chemical  changes  involved  are  complex,  but 
the  chief  products  are  ethyl  alcohol  and  carbon-dioxide  gas.  A  little 
glycerin,  succinic  acid,  and  other  bodies  may  be  formed.  The  fungus 
is  always  floating  in  the  air,  so  that  when  saccharine  fluids  are  ex- 
posed to  it  the  fermentation  proceeds  of  itself.  Two  parts  of  sugar 
yield  approximately  one  of  alcohol. 

Alcohol  may  be  derived  from  any  starches  or  sugars  by  fermenta- 
tion, but  in  the  United  States  the  chief  sources  of  alcoholic  beverages 
are  grains  such  as  oats,  corn,  wheat,  rye  and  barley,  molasses  and 
fruits,  such  as  grapes,  apples,  peaches,  and  to  a  limited  extent  pears, 
apricots,  figs,  prunes,  cherries  and  berries. 


STIMULANTS  AND   BEVEKAGES  263 

About  150,000,000  gallons  of  spirits  are  produced  annually  in  the 
United  States  from  grains  and  molasses,  and  5,500,000  gallons  of 
fruit  brandy  (U.  S.  Dept.  of  Agriculture  Bull.  No.  269,  1906). 

There  are  no  civilized  races,  and  few  uncivilized  or  semi- civilized 
people,  with  the  exception  of  Mohammedans,  Buddhists,  the  north- 
ern Eskimos,  and  one  or  two  other  tribes  mentioned  below,  who 
do  not  practice  the  distillation  of  alcohol  in  some  form  or  other 
from  the  materials  most  available.  For  example,  the  spirit  fermented 
from  the  potato  is  drunk  in  Lombardy,  and  that  from  rice  in  Japan, 
and  the  Fiji  Islanders  use  a  drink,  "  Tcava,"  made  by  fermenting  with 
their  own  saliva  the  Piper  methysticum.  Even  the  stems  of  plants 
are  used,  as  in  the  case  of  alcoholic  beverages  made  from  the  sugar 
cane  and  the  palm.  (See  also  p.  241.) 

General  Discussion  of  the  Value  of  Alcohol. —  The  question 
whether  alcohol  is,  properly  speaking,  a  food,  or  is  only  to"  be 
regarded  as  a  beverage  and  stimulant  without  power  of  nutrition, 
has  given  rise  to  much  warm  discussion,  and  it  invariably  plays  an 
important  role  among  the  advocates  of  teetotalism.  A  full  presen- 
tation of  the  alcohol  question  would  be  foreign  to  the  limits  of  the 
present  work,  but  the  following  general  propositions  comprise  the 
belief  of  many  authorities  who  have  devoted  careful  research  to 
this  exceedingly  important  topic : 

1.  The  use  of  alcohol  in  any  form  is  unnecessary  for  the  human 
organism  in  health.     It  does  not  exist  as  a  natural  product.     The 
very  lowest  types  of  man  —  Australian  and  many  Polynesian  sav- 
ages —  know  nothing  of  it,  and  drink  only  water  and  fresh  fruit  juice, 
such  as  that  of  the  cocoanut,  although  they  speedily  acquire  a  fond- 
ness for  alcoholic  beverages  when  given  them. 

2.  A   large   number   of   persons   are   undoubtedly   better   without 
alcohol  and  may  prolong  their  lives  by  total  abstinence. 

3.  The  lifelong  use   of   alcohol   in  moderation   as   an   occasional 
beverage  with  meals  does  not  necessarily  shorten  the  duration  of 
life  or  induce  disease  in  some  persons,  while  in  others  it  undoubtedly 
produces  gradual  and  permanent  changes,  chiefly  of  a  cirrhotic  char- 
acter, in  the  blood  vessels,  nerves  and  in  the  viscera,  especially  the 
liver  and  kidneys.     These  alterations,  which  may  be  slow  and  subtile 
in  character,  may  not  in  themselves  materially  impair  the  health  or 
cause    an   ultimately   fatal   result,   but   they  tend   to   weaken   vital 
organs  and  produce  premature  senility,  so  that  if  the  patient  acquire 
any  severe  disease  —  as,  for  example,  an  acute  infection,  like  pneu- 
monia, or  a  chronic  one,  like  tuberculosis  —  the  resistance  of  the  body 
to  the  invasion  of  the  disease  is  impaired.     There  is  a  prevalent 


264  STIMULANTS,   BEVERAGES,   CONDIMENTS 

belief  that  these  cirrhotic  changes  are  as  much  due  to  toxic  products 
of  indigestion  caused  by  alcohol  as  to  the  alcohol  per  se. 

4.  There   are   many  persons   whose   constitutional   inheritance   of 
inebriety  is  such  that  they  should  be  warned  particularly  against  the 
use  of  alcohol,  and  in  some  such  cases,  as,  for  example,  among  those 
who  are  subjects  of  well-marked  gouty  diathesis,  it  is  better  that  its 
use  should  be  forbidden  imperatively. 

5.  The  abuse  of  alcoholic  stimulation  is  invariably  injurious,  al- 
though the  extent  to  which  evil  influences  become  manifest  depends 
upon  the  constitution  of  the  individual,  in  connection  with  the  fac- 
tors of  heredity,  environment  and  activity  of  excretory  organs. 

6.  There  are  a  few  diseases  in  which  the  temporary  use  of  alcohol 
is  of  positive  service,  and  there  are  certain  cases  in  which  it  becomes 
a  necessity  in  order  to  prolong  life. 

7.  In  certain  cases  of  malnutrition  and  malassimilation  of  food, 
alcohol  is  itself  a  food,  and  its  consumption  under  proper  direction 
results  in  an  increase  of  body  weight  and  strength  and  improve- 
ment of  functional  activity.     These  results  are  accomplished  in  part 
through  the  action  of  the  alcohol  as  a  definite  food,  and  in  part 
through   its   remarkable  effect  in   force  production.     The   latter   is 
due   to    its   own    direct   combustion,    by   which    in   chronic    disease 
and  in  critical  acute  and  exhausting  affections  it  spares  that  of  the 
tissues  of  the  body.     This  value  exists  especially  in  the  malt  bever- 
ages. 

Although  alcohol  is  such  a  strong  force  producer  and  heat  gen- 
erator, its  effect  in  this  direction  is  very  soon  counterbalanced  by 
its  stronger  influence  in  lowering  the  general  tone  of  the  nervous 
system  and  in  producing  positive  degeneration  in  the  tissues.  In 
the  condition  of  health  more  food  usually  is  eaten  and  more  force 
developed  than  is  actually  necessary  for  the  body,  and  there  is  al- 
ways a  reserve  supply  of  energy  on  hand  which  may  be  utilized 
for  any  extraordinary  exertion,  and  hence  the  constant  use  of  alcohol 
as  a  food  or  stimulant  in  health  is  both  unnecessary  and  inadvisable. 
When  alcohol  is  consumed  in  health  in  addition  to  a  normal  or  ex- 
cessive quantity  of  solid  food  by  its  more  ready  combustion  it  pre- 
vents the  coniplete  oxidation  of  the  latter  and  favors  accumulation 
of  suboxidized  waste  products  which  are  always  harmful  in  the 
system.  Excesses  in  eating  are  thus  doubly  aggravated  by  the  ef- 
fects of  alcohol.  It  is  the  almost  universal  testimony  of  army 
surgeons  and  the  experience  of  those  who,  like  Greely,  Stanley,  and 
others,  have  led  long  and  perilous  exploring  expeditions,  involving 
great  fatigue  and  unusual  endurance,  that  muscular  overwork  and 


STIMULANTS  AND   BEVERAGES  265 

climatic  hardships  are  endured  much  better  if  alcohol  is  entirely  ab- 
stained from. 

It  often  has  been  found  in  armies  that  when  good  food  was  at 
hand  the  issue  of  alcohol  with  the  regular  ration  produced  an  in- 
creased percentage  of  sickness  and  of  incapacity  for  work. 

While  all  this  applies  to  prolonged  effort  of  any  kind  and  to 
conditions  where  other  food  can  be  obtained  and  assimilated,  it 
does  not  detract  from  the  fact  that  alcohol  is  a  most  helpful  food 
and  stimulant  in  emergencies  when  other  food  cannot  be  had  or 
when  the  body  is  temporarily  endangered  from  acute  disease  and 
the  higher  rate  of  combustion  in  fever,  or  from  failure  to  assimilate 
other  nourishment. 

Major  Woodruff,  U.  S.  A.,  says :  "  Spirits  can  never  be  used 
in  the  army  as  a  regular  issue;  the  practice  is  thoroughly  vicious, 
and  was  virtually  abandoned  seventy  years  ago.  On  extraordinary  oc- 
casions of  great  fatigue  they  are  allowable  in  moderation.  Under 
such  temporary  stimulation  the  men  will  brace  up  and  perform  the 
necessary  work  of  making  earthworks,  etc.,  when  without  it  they' 
would  be  too  exhausted  to  do  anything.  Without  stimulation  a 
man  is  not  worth  much  after  he  has  made  a  forced  march  of  forty 
miles/' 

The  problem  whether  the  world  as  a  whole  is  better  or  worse  for 
the  existence  of  alcohol  aside  from  all  ethical  questions,  and  viewed 
merely  from  the  scientific  standpoint  of  the  influence  of  alcohol 
upon  mortality,  is  difficult  of  solution,  for  to  offset  the  numerous 
cases  of  fatal  alcoholism  and  the  still  larger  number  of  cases  of  dis- 
eases which  would  not  presumably  be  fatal  without  the  existing  con- 
dition of  chronic  alcoholic  poisoning  of  the  system,  are  very  many 
cases  in  which  life  is  undoubtedly  saved  by  the  prompt  resort  to 
this  food  and  stimulant  and  its  energetic  use.  So  long  as  man  is 
exposed  to  hardships  and  conditions  arising  from  improper  and  de- 
ficient food  supply  as  well  as  to  the  numerous  infectious  diseases 
to  which  he  is  heir,  alcohol  should  be  regarded  rather  as  a  bless- 
ing than  a  curse,  for  there  is  no  form  of  stimulant  and  food  combined 
or  stimulant  alone  which,  taken  all  in  all,  can  be  relied  upon  so  com- 
pletely in  cases  of  emergency.  Alcohol  when  taken  alone  will  pro- 
long life  beyond  the  period  at  which  it  would  terminate  from  starva- 
tion. 

Physiological  Action. —  I.    As  a  Food. —  As  a  food,  alcohol  adds  to 

the  nutrition  of  the  body  by  its  prompt  absorption,   requiring  no 

preliminary  preparation  by  the  digestive  organs,  which  are  therefore 

not  taxed  in  any  degree,  and  it  is  immediately  conveyed  in  the  general 

20 


266  STIMULANTS,   BEVERAGES,   CONDIMENTS 

circulation  to  the  liver  and  other  parts  of  the  system.  The  chemical 
changes  involved  in  the  assimilation  of  this  form  of  hydrocarbon  are 
ill  understood.  Alcohol,  even  when  digested  in  considerable  quantity, 
does  not  reappear  to  any  extent  unaltered  in  the  urine,  and,  if  not 
taken  in  excess,  it  is  not  exhaled  from  the  breath,  demonstrating  that 
its  combustion  is  complete.  This  combustion  results  in  the  formation 
of  water  and  carbon  dioxide.  The  fact  that  the  body  weight  may 
increase  under  its  use,  and  the  storage  of  fat  in  the  tissues  increase 
to  an  abnormal  degree,  does  not  prove  that  the  alcohol  itself  has 
entered  into  their  structure,  for  its  action  may  be  exerted  through 
modification  of  oxidation  processes  or  by  preventing  the  burning  up  of 
other  food  materials.  The  fool  value  of  alcohol,  is,  however,  easily 
surpassed  if  too  much  be  taken,  and  usually  not  more  than  V/2  oz.  of 
an  equivalent  of  pure  alcohol  can  be  utilized  daily  within  food  limits. 

Writing  of  the  nutritive  value  of  alcohol  in  disease,  Atwater  says : 

"  It  does  not  require  digestion,  is  absorbed  by  the  stomach,  and 
presumably  by  the  intestine,  with  great  ease.  Outside  of  the  body 
it  is  oxidized  very  readily,  within  the  body  it  appears  to  be  quickly 
burned,  and  it  supplies  a  large  amount  of  energy."  He  has  further 
proved  in  calorimeter  experiments  that  alcohol  protects  body  pro- 
tein and  fat  from  oxidation. 

It  is,  however,  inferior  to  carbohydrates  in  regard  to  protein  pro- 
tection and  in  some  cases  may  increase  protein  consumption,  as,  for 
example,  when  taken  in  such  excess  as  to  affect  the  nervous  system 
and  inhibit  normal  metabolism. 

Bauer  says:  "Alcohol,  in  consequence  of  its  fat-sparing  action, 
behaves  in  the  character  of  a  food."  The  sugar  which  is  contained 
in  considerable  quantity  in  sweet  wines,  liqueurs,  etc.,  is  an  addi- 
tional source  of  nourishment  or  of  fat  production.  It  is  a  matter  of 
common  observation  that  many  heavy  drinkers  are  stout  so  long  as 
their  digestion  remains  unimpaired.  Heavy  drinkers  are  often  heavy 
eaters,  and  may  be  as  unable  to  control  their  appetite  for  food  as 
for  drink.  This  of  course  does  not  apply  to  cases  of  alcoholic  gas- 
tritis, in  which,  temporarily  at  least,  all  desire  for  food  may  be  in 
abeyance. 

II.  As  a  Stimulant  to  the  Nerves  and  Circulation. —  The  influence 
of  alcohol  upon  the  nervous  system  in  moderate  doses  is  to  quicken  the 
transmission  and  enhance  the  effect  of  nerve  currents,  accelerating 
slightly  the  heart  action  and,  to  a  lesser  degree,  the  respiration, 
while  the  mental  processes  are  stimulated  in  part  by  its  direct  influ- 
ence upon  the  cerebrum,  and  in  part  also  by  the  greater  rapidity  of 
the  circulation. 


STIMULANTS  AND  BEVERAGES  267 

If  alcohol  is  given  in  large  doses  or  at  too  frequent  intervals,  it 
may  overstimulate  the  heart,  which  subsequently  becomes  exhausted. 

III.  Action  upon  the  Muscular  System. —  Experiments  to  test  the 
sustaining  power  of  alcohol  were  made  upon  three  regiments  of  the 
British  army  and  reported  in  1899.     The  men  were  subjected  to 
fatiguing  exercises.     To  one  regiment  a  ration  of  whisky  was  allowed, 
to  a  second  a  ration  of  malt  liquor,  and  to  the  third  no  alcohol.     The 
men  taking  whisky  exhibited  more  energy  for  about  four  days  than 
either  of  the  other  groups,  but  then  became  fatigued  and  weak; 
whereas  those  taking  none  steadily  gained  in  endurance,  and  those 
taking  malt  liquor  showed  an  intermediate  condition.     As  a  result 
of  these  experiments,  the  use  of  liquor  was  absolutely  forbidden  in 
Kitchener's  Soudanese  campaign,  which  was  characterized  by  remark- 
able immunity  from  disease  in  the  Desert.     Alcohol  is  usually  for- 
bidden to  athletes  in  training,  for  although  it  may  temporarily  lessen 
muscular  fatigue,  and  increase  muscular  force,  it  soon  reduces  the 
powers  of  endurance. 

IV.  Action  upon  the  Body  Temperature. —  The  physiological  effect 
of  alcohol  upon  the  body  temperature  proceeds  primarily  from  its 
stimulating  influence  upon  the  vasomotor  nerves.     In  moderate  doses, 
alcohol,  by  quickening  the  rapidity  of  the  circulation  and  by  dilating 
the  peripheral  blood  vessels,  enables  more  blood  to  reach  the  surface 
of  the  body  and  to  pass  through  the  superficial  capillaries  in  a  given 
time,  and  hence  there  is  a  tendency  to  lower  slightly  the  body  tempera- 
ture.    On  the  other  hand,  the  combustion  of  the  alcohol  itself  within 
the  body  results  in  the  production  of  a  large  number  of  heat  units. 
The  total  balance  of  these  processes  is  usually  on  the  side  of  an  ab- 
solute reduction  of  the  temperature.     This  effect  is  so  slight,  how- 
ever, that  alcohol  cannot  be  relied  upon  solely  for  reduction  of  tem- 
perature in  fevers. 

As  a  result  of  an  elaborate  series  of  experiments  made  by  Reichert 
to  determine  the  action  of  alcohol  on  animal  heat  functions,  he  con- 
cludes "  that  alcohol  does  not  affect  the  total  quantity  of  heat  pro- 
duced; that  more  heat  is  dissipated  than  produced;  that  the  fall  of 
temperature  is  due  to  the  excess  of  dissipation,  and  is  in  direct  pro- 
portion; and  that  in  all  likelihood  alcohol,  by  undergoing  oxidation, 
yields  energy  in  the  form  of  heat,  thus  conserving  the  tissues  and 
acting  as  a  food." 

V.  Action  0,9  a  Diuretic. —  Alcohol  in  some  persons  is  a  strong 
diuretic  in  health,  and  its  effect  depends  largely  upon  the  variety  of 
the  beverage  used.     For  some  persons  gin  has  a  much  more  decided 
diuretic  action  than  other  strong  liquors,   such   as  rum  or  brandy, 


268 


STIMULANTS,   BEVERAGES,   CONDIMENTS 


and  in  many  beer  possesses  a  diuretic  action  which  indicates  a  special 
stimulating  effect  upon  the  total  quantity  of  urine  excreted  beyond 
that  produced  by  a  similar  bulk  of  water,  but  the  total  quantity  of 
urea,  sulphates,  and  phosphates  eliminated  is  diminished.  Chitten- 
den  found  that  uric-acid  excretion  is  doubled.  As  a  general  rule, 
alcohol  which  is  moderately  diluted,  and  which  is  taken  upon  an 
empty  stomach,  is  much  more  promptly  absorbed  and  possesses  a 
stronger  diuretic  action  than  when  taken  with  food  or  when  given 
in  a  concentrated  form.  Owing  to  its  irritant  action  upon  the  kid- 
neys alcohol  cannot  be  relied  upon  as  a  diuretic  in  nephritis. 

VI.  Action  on  Mucous  Membranes. —  Strong  alcohol  is  astringent 
to  mucous  surfaces,  and  is  sometimes  used  diluted  with  equal  parts 
of  water  as  a  gargle  for  sore  throat.     Claret,  which  also  contains 
tannin,  may  be  employed  in  this  way. 

If  taken  in  too  large  quantity  or  too  strong,  the  astringent  effect 
upon  the  stomach  is  highly  irritating,  causing  local  congestion,  and 
inflammation.  The  tongue  becomes  coated,  and  the  appetite  is  de- 
stroyed as  well  as  the  secreting  power  of  the  gastric  glands. 

VII.  Action  upon   Gastric  Digestion. —  Taken  with   food  in  the 
stomach,  alcohol  in  small  quantities,  not  exceeding  the  equivalent 
of  a  quarter  of  an  ounce  of  the  pure  substance,  given  in  the  form 
of  any  dilute  alcoholic  beverage,  does  not  inhibit  the  action  of  the 
gastric  juice,  but  may  stimulate  its  secretion  so  that,  as  Moleschott 
says,  "  a  glass  or  two  of  good  old  wine  increases  the  quantity  of 
gastric  juice,  which  performs  mainly  the  digestion  of  albuminous 
foods."     In  larger  quantities,  or  if  the  gastric  juice  is  weak,  alcohol 
precipitates  pepsin,  coagulates  the  albuminous  materials  of  the  food 
and  greatly  retards  if  it  does  not  altogether  destroy  gastric  digestion. 

Some  interesting  experiments  were  reported  by  Eoberts  (Lec- 
tures on  Dietetics  and  Dyspepsia)  upon  the  effect  of  malt  liquors 
on  gastric  digestion.  They  were  conducted  by  adding  together  2 
grams  of  dried  beef-fiber,  0.15  c.  c.  of  hydrochloric  acid,  1  c.  c.  of 
glycerin  extract  of  pepsin,  and  varying  quantities  of  malt  liquor, 
with  water  up  to  1 00  c.  c.  The  result  is  tabulated : 


PROPORTION  OF  MALT  LIQUORS 
CONTAINED  IN  THE  DIGEST- 
ING MIXTURE. 

TIME  IN  WHICH  DIGESTION  WAS  COMPLETED. 
(NORMAL,  100  MINUTES.) 

Burton  ale. 

Light  English 
table  beer. 

Lager  beer. 

10  per  cont  

115  minutes. 
140 
200          " 
Embarrassed. 

100  minutes. 
115          " 
140 
180          " 

100  minutes. 
115 
140          " 
180 

20     "       "          

40     "       "                     

60     "      "              

STIMULANTS  AND   BEVERAGES  269 

In  considering  the  relation  of  alcohol  to  other  foods,  the  fact 
should  be  emphasized  that  monotony  of  diet  with  bad  cooking  of 
coarse,  tasteless  food,  especially  when  associated  with  overwork,  may 
be  a  potent  factor  in  establishing  a  liking  for  liquors  among  the 
poor,  particularly  in  the  United  States,  where  among  the  poorer 
classes  the  art  of  varying  the  diet  and  of  serving  food  in  an  agree- 
able and  properly  seasoned  manner  is  imperfectly  understood.  Osier 
endorses  the  opinion  that  more  ill  arises  from  abuses  of  eating  than 
of  drinking,  especially  in  America. 

VIII.  Alcohol  Absorption. —  Alcohol   is   highly   diffusible,   and   is 
promptly  absorbed  from  mucous  surfaces  as  well  as  from  subcutaneous 
tissue. 

When  taken  into  an  empty  stomach,  it  is  rapidly  absorbed,  and 
its  influence  is  exerted  suddenly.  When  there  is  food  in  the  stomach, 
some  of  the  alcohol  is  temporarily  taken  up  by  it  like  water  by  a 
sponge,  its  absorption  is  delayed,  and,  as  its  combustion  is  rapid, 
the  system  is  less  likely  to  become  surcharged  with  it. 

Alcohol  is.  well  absorbed  from  the  rectum,  and  to  patients  who 
for  any  reason  are  unable  to  retain  it  in  the  stomach  it  may  be 
given  in  enemata.  For  this  purpose  it  is  best  to  use  an  ounce  of 
whisky  or  brandy  diluted  with  3  or  4  parts  of  water. 

Hypodermic  Use. —  Very  little  alcohol  can  be  made  to  pass  into  the 
body  by  rubbing  it  upon  the  skin,  although  it  is  a  diffusible  sub- 
stance, but  it  is  promptly  absorbed  when  injected  hypodermically. 
Owing  to  the  local  irritant  action  of  alcohol,  not  over  a  drachm  or 
two  of  spirits  should  be  placed  beneath  the  skin  at  any  one  point, 
for  it  is  often  quite  painful.  The  surface  should  be  rubbed  to  pro- 
mote absorption.  In  emergency,  an  ounce  or  more  may  be  given 
in  this  way  in  divided  doses. 

IX.  Elimination. —  It  may  be  regarded  as  proved  that  when  taken 
in  moderation  alcohol  is  completely  consumed  within  the  body,  or 
so  completely  that  a  mere  trace  escapes  in  the  urine  and  perspiration, 
and  a  little  more  in  the  exhaled  air.     If  the  dosage  of  alcohol  is 
large,   however,   its   elimination,   unaltered,   becomes   proportionately 
active,  although  it  is  still  consumed  in  large  amount  in  the  body. 

X.  Alcohol  Poisoning. —  This  topic  will  be  more  conveniently  dis- 
cussed with  the  treatment  under  the  heading  Alcoholism. 

XI.  Alcohol    and    Climate. —  Many    persons    find    that   they    can 
drink  more  spirits  and  wine  during  a  prolonged  residence  in  a  cli- 
mate like  that  of  England  without  ill  effect  than  they  can  in  the  more 
stimulating  climate  with  greater  extremes  of  temperature  which  exist 
in  many  parts  of  the  United  States.     If  men  are  to  be  exposed  to  cold 


270  STIMULANTS,   BEVERAGES,   CONDIMENTS 

and  hardship  for  a  considerable  period  of  time  it  is  unwise  to  indulge 
freely  in  alcoholic  drinks  on  account  of  the  fall  in  the  body  tempera- 
ture, which  is  promoted  by  the  external  cold  when  alcohol  relaxes  the 
capillaries.  In  illustration  of  this  principle,  a  story  is  told  of  a 
party  of  engineers  who  were  lost  during  the  winter  in  the  Kocky 
Mountains,  where,  after  prolonged  exposure  to  cold  and  hardship, 
they  were  one  night  obliged  to  sleep  without  shelter  with  the  ther- 
mometer below  zero.  They  had  whisky  with  them,  but  little  food; 
some  of  the  party  drank  heavily,  others  drank  in  moderation,  and 
a  few  of  the  wiser  took  no  alcohol  at  all.  In  the  morning  the  latter 
awoke,  cold  but  refreshed  by  the  night's  rest,  while  others  who  drank 
in  moderation  had  suffered  far  more  from  the  exposure,  and  one  or 
two  of  those  who  had  drunk  freely  were  frozen  to  death. 

Otto  Snell  interrogated  sixty  expert  mountain-climbers,  and  only 
five  declared  that  liquor  was  not  injurious  if  taken  before  or  during 
their  exertions. 

In  the  Arctic  expeditions  of  Greely,  De  Long,  and  others,  although 
pure  alcohol  was  carried  for  cooking  purposes,  stringent  regulations 
were  enforced  to  prevent  the  men  from  drinking  alcoholic  beverages, 
which  were  kept  only  for  emergencies  and  sickness. 

CLINICAL,   USES    OF   ALCOHOL, 

1.  Use  as  a  Tonic. —  Very  moderate  doses  of  alcohol  increase  the 
flow  of  gastric  juice,  and  for  this  reason  it  may  be  employed  in  cases 
such  as  the  following:     1.  By  those  whose  nervous  system  is  readily 
overtaxed  and  who  when  fatigued  or  worried  lose  all  appetite.     2. 
By  persons  of  sedentary  habits  who  have  enfeebled  digestion.     3.  In 
protracted  convalescence  from  severe  forms  of  acute  disease.     For  any 
of  these  patients  a  little  whisky  and  water,  or  a  glass  of  simple  bit- 
ters may  be  ordered  to  be  taken  directly  before  meals  in  order  to 
improve  the  "  tone "  of  the  stomach.     In  all  cases  care  should  be 
exercised,  especially  among  persons  who  may  possibly  inherit  the  al- 
coholic habit,  that  the  beverage  be  not  prescribed  too  often,  for  many 
cases  of  chronic  alcoholism  originate  among  persons  who  begin  by 
resorting  to  this  food  and  stimulant  to  tide  them  over  emergencies, 
and  who  find  when  the  emergency  is  passed  that  they  are  unable  to  re- 
linquish  the   acquired   fondness   for  the   drink.     Major   Charles   E. 
Woodruff  says  that  experience  based  on  service  of  the  troops  in  the 
Philippines  "lias  demonstrated  that  in  a  hot  climate  the  moderate  use 
of  intoxicating  drink  is  essential  to  continued  health  and  efficiency." 

2.  Use  as  a  Vascular  and  Cardiac  Stimulant. —  If  there  is  general 
arterial  relaxation  from  debilitating  disease,  the  combined  action  of 


STIMULANTS  AND   BEVERAGES  271 

alcohol  in  strengthening  the  heart  and  regulating  the  caliber  of  the 
blood  vessels  is  sometimes  useful.  For  this  purpose  it  is  best  to 
use  strong  liquors,  such  as  brandy  or  whisky,  which  vary  little 
in  composition,  and  which  may  be  diluted  according  to  need.  In 
cases  of  sudden  heart  failure  occasioned  by  shock,  fainting,  etc.,  it 
is  best  to  give  alcohol  in  the  form  of  diluted  spirits,  when  required. 

It  is  an  interesting  fact  that  the  mechanical  action  of  deglutition 
stimulates  the  heart  action  and  increases  the  rate  of  pulse  beats  by 
ten  or  twenty  in  the  minute.  Stimulants  sipped  slowly  by  repeated 
acts  of  swallowing  for  this  reason  may  have  a  greater  effect 
than  the  same  quantity  of  fluid  drunk  all  at  once.  In  extreme 
emergencies,  as,  for  example,  in  shock  from  prolonged  anaesthesia, 
when  alcohol  is  given  by  hypodermic  injection,  the  stimulation  of 
the  pulse  may  be  appreciated  in  two  or  three  minutes.  A  little  more 
time  is  required  for  the  full  effect  if  the  stimulant  is  given  by  the 
stomach  or  rectum.  The  benefit  of  alcohol  is  further  shown  by  the 
tongue  and  skin  becoming  more  moist,  by  the  slowing  of  the  pulse,  and 
by  the  breathing  becoming  more  tranquil.  The  very  soft  pulse  of  con- 
siderable volume  may  diminish  in  volume  under  the  use  of  alcohol, 
but  it  becomes  firm  and  of  better  character,  showing  an  improvement 
in  the  arterial  tone. 

3.  Use  in  Nervous  Diseases. —  Alcohol  is  occasionally  of  service  for 
certain  diseases  of  the  nervous  system.     Neuralgic  pains  are  some- 
times allayed  by  the  use  of  alcoholic  drinks  which  contain  volatile 

'ethers,  but  they  should  be  prescribed  with  caution.  In  neuralgic 
or  nervous  affections,  such  as  hysteria,  which  are  more  or  less  chronic, 
it  is  well  to  observe  that  many  of  the  so-called  proprietary  elixirs, 
nerve  tonics,  etc.,  which  are  recommended  for  cases  of  fhis  nature, 
and  especially  for  treatment  of  nervous  prostration,  contain  a  large 
percentage  of  alcohol,  and  their  use  is  liable  to  establish  permanent 
alcoholism. 

4.  Use  in  Fevers. —  Usually  in  acute  febrile  diseases,  such  as  pneu- 
monia, in  which  the  emergency  of  cardiac  failure  or  great  prostra- 
tion may  be  anticipated,  it  is  better  to  withhold  alcohol  until  there 
are  definite  indications  for  its  use  than  it  is  to  prescribe  it  in  a  routine 
manner  at  the  commencement  of  the  disease ;  its  effect  when  actually 
needed  is  enhanced  if  it  has  not  already  been  given  for  too  long  a 
time.     For  persons  with  feeble  constitutions,  however,  and  for  aged 
people  it  may  be  necessary  to  commence  the  use  of  alcohol  at  an  earlier 
period.     In  urgent  cases  full  doses,  such  as  an  ounce  of  whisky  an 
hour,  may  become  necessary  for  a  few  times,  and  the  quantity  and 
intervals    for   its    administration   may   then   be    reduced    gradually. 


272  STIMULANTS,   BEVERAGES,   CONDIMENTS 

Usually  however,  when  the  stimulating  and  supporting  influence  of 
alcohol  is  needed  it  is  better  to  give  it  in  quite  frequent  doses  and  in 
moderate  quantity  than  in  large  amount  infrequently.  The  stimula- 
tion is  then  more  uniform  and  constant,  and  the  digestive  organs  are 
less  likely  to  be  deranged. 

There  is  at  present  a  strong  reaction  against  the  prescribing  of 
large  doses  of  alcohol  in  pneumonia  and  other  infectious  diseases, 
as  in  fevers  in  general,  and  personally  I  make  much  less  use  of  it 
than  formerly,  and  in  a  majority  of  serious  cases  of  pneumonia  and  ty- 
phoid fever,  I  have  witnessed  recovery  without  its  use  at  any  time 
throughout  the  disease.  In  the  London  hospitals  forty  years  ago,  the 
total  cost  of  alcoholic  drink  used  was  nearly  three  times  that  of  milk, 
but  at  the  present  time  this  proportion  has  been  reversed. 

The  volatile  stimulants  such  as  ether,  camphor,  aromatic  ammonia, 
and  digitalis  may  be  employed  often  with  greater  benefit  than 
alcohol,  and  as  an  antipyretic  the  value  of  alcohol  is  slight  and  unre- 
liable. 

The  indications  for  the  use  of  alcohol  in  fevers  are  found  in  the  pre- 
dominance of  one  or  more  of  the  following  symptoms:  Increased 
weakness  or  faintness,  low  muttering  delirium  continued  even  when 
the  patient  is  undisturbed,  tremor  of  the  tongue  and  hands,  great 
dryness  of  the  tongue,  extreme  feebleness  of  the  voice,  irregularities 
in  the  respiration  and  pulse,  enfeebled  or  irregular  heart  action,  and 
absence  of  either  of  the  cardiac  sounds.  In  using  alcohol  in  fevers 
if  the  odor  persists  in  the  breath  and  the  pulse  is  not  improved, 
or  the  patient  becomes  more  delirious,  too  much  is  being  given,  and 
the  dosage  should  be  reduced. 

Proper  Time  for  Giving  Alcoholic  Beverages. —  When  needed  as  a 
tonic,  the  beverage  should  be  given  either  immediately  before  or  in 
connection  with  meals,  in  order  that  its  effect  may  be  modified  by 
that  of  other  foods.  There  is  less  fear  of  establishing  a  craving  for 
drink  if  this  rule  be  observed.  It  is  the  habit  of  drinking  between 
meals  without  definite  purpose  which  is  particularly  dangerous. 

In  some  cases  of  neurasthenia,  anasmia,  etc.,  it  may  be  advisable 
to  recommend  a  glass  of  claret  or  sherry  between  the  principal  meals, 
and  it  should  be  taken  with  some  article  of  light  and  easily  digestible 
food,  such  as  a  biscuit  or  sandwich. 

There  are  some  patients  having  chronic  atonic  dyspepsia  or  limited 
nervous  energy  for  whom  it  is  better  to  prescribe  alcohol  half  an 
hour  before  eating  in  order  that  its  stimulating  influence  may  be 
Mt  in  the  system  before  the  nervous  forces  are  called  upon  for 
digestive  functions. 


STIMULANTS   AND   BEVERAGES  273 

Selection    of    the    Proper    Form    of    Alcoholic    Beverage. —  The 

stomach  is  much  less  likely  to  be  upset  by  adhering  to  a  single 
form  of  beverage  than  by  making  frequent  changes.  Persons  hav- 
ing robust  physiques  may  be  able  to  assimilate  several  kinds  of  wines, 
including  champagne,  at  dinner,  followed  by  liquors  and  brandy;  but 
these  beverages,  if  taken  in  such  variety  without  food,  will  almost 
invariably  derange  the  stomach.  The  combination  of  whisky  and 
beer  or  strong  liquors  and  champagne  will  promptly  disagree  with 
many  persons  who  could  take  either  form  of  alcohol  alone  with  im- 
punity. In  fever  the  stomach  is  always  temporarily  enfeebled,  and 
the  importance  of  adhering  to  one  simple  form  of  alcoholic  beverage 
is  emphasized.  It  may  be  changed  from  time  to  time  in  conformity 
with  the  taste  of  the  patient,  but  mixtures  never  should  be  given. 

Beer,  ale,  porter,  and  stout,  cannot  be  drunk  by  some  persons 
without  producing  a  subsequent  feeling  of  lassitude  and  drowsiness 
with  headache  and  suffusion  of  the  face,  and  yet  diluted  spirits  may 
be  well  borne.  Some  persons  find  that  sherry  produces  acid  dys- 
pepsia, and  others  find  that  different  sweet  wines,  such  as  port, 
similarly  disagree,  and  in  others  again  they  excite  attacks  of  gout. 
When  porter,  ale,  or  stout  do  not  derange  the  stomach,  they  may 
be  drunk  advantageously  by  women  who  are  weakened  by  prolonged 
suckling.  Alcohol  should  be  emphatically  forbidden  in  all  forms 
of  gonorrhoea  and  syphilis,  and  a  single  infringement  of  this  rule 
may  aggravate  the  complaint.  Some  clinicians  prefer  the  use  of 
wines  which  are  well  charged  with  volatile  compound  ethers  as  a 
stimulant  for  enfeebled  heart  action  and  weak  digestion.  The  use 
of  beer  as  a  beverage  for  fevers  is  common  in  Continental  Europe,  but 
not  in  the  United  States.  Passing  fashion  to  some  extent  influences 
the  variety  of  alcoholic  beverage  consumed,  as  illustrated  by  the  fact 
that  in  this  country  the  annual  importation  of  Scotch  whisky  has 
lately  risen  from  30,000  to  100,000  gallons  for  a  single  firm.  Eum 
and  port  are  much  less  drunk  than  formerly  in  the  United  States. 

As  a  preventive  of  drunkenness  and  the  evils  of  chronic  alcohol- 
ism, the  introduction  of  the  milder  malt  liquors  into  this  country  to 
partially  supersede  the  use  of  strong  spirits  has  proved  a  decided 
advantage.  The  total  annual  consumption  of  all  alcoholic  beverages 
in  the  United  States  exceeds  one  billion  gallons.  In  1870  the  per 
capita  consumption  of  distilled  liquors  was  2.07  gallons,  and  twenty- 
five  years  later  this  fell  to  1.12  gallons,  whereas  during  the  same 
period  the  consumption  of  malt  liquors  rose  from  5.31  to  14.95  gal- 
lons. The  consumption  of  wines  has  remained  at  about  0.32  gallon. 

There  is  prevalent  a  widespread  tendency  towards  restriction  of 


274  STIMULANTS,   BEVERAGES,   CONDIMENTS 

the  use  of  alcoholic  beverages  in  the  United  States,  England,  Canada, 
and  other  British  Colonies,  and  in  two-thirds  of  the  United  States 
in  1908  the  saloon  had  been  abolished  by  prohibition  laws. 

Malt  Liquors 

Beer. —  The  lager-beer  industry  was  introduced  into  the  United 
States  in  1842. 

Composition. —  Beer  contains  alcohol  in  strength  varying  between 
3.  and  8  volumes  per  cent  (sometimes  10  per  cent).  Besides 
this  alcohol  and  much  water,  beer  contains  a  variety  of  ingredients, 
such  as  bitter  and  resinous  extractives  from  hops,  sugar,  dextrin, 
albuminates,  glycerin,  free  acids,  and  a  trace  of  ash.  The  sugar  of 
beer  is  fattening,  and  the  bitter  substances  are  more  or  less  of  a 
stomachic  tonic. 

By  process  of  manufacture  much  beer  is  made  to  contain  only 
water,  alcohol,  and  bitter  principles.  Hop  extracts  possess  a  nar- 
cotic influence,  and  hence  beer  may  give  rise  to  drowsiness,  whereas 
other  alcoholic  beverages  —  like  champagne  or  whisky  —  prove  en- 
livening. This  effect  is,  however,  quite  variable. 

Beer  produces  biliousness  in  persons  of  weak  digestion.  It  is 
sometimes  called  "  fluid  bread/'  but  the  expression  conve}rs  a  wholly 
exaggerated  idea  of  its  food  value,  although  it  is  often  fattening 
when  drunk  in  large  quantity. 

Beer  Brewing. —  Malt  is  the  name  given  to  any  germinating  ce- 
real, but  to  prepare  it  for  beer  brewing,  malt  is  made  from  barley 
grains  as  follows:  The  grain  is  steeped  in  water  at  a  temperature 
which  causes  germination  and  the  development  of  the  ferment  dias- 
tase. It  is  next  couched  and  "  floored/'  during  which  process  ger- 
mination continues,  and  it  is  finally  kiln-dried. 

Brewing  of  beer  is  accomplished  as  follows:  The  prepared  bar- 
ley malt  is  first  cleaned  by  screening,  sifting,  and  blowing,  is  crushed 
and  then  "  mashed  "  or  infused  with  water  in  large  tubs  at  a  proper 
temperature.  This  process  extracts  the  existing  sugar  and  dextrin 
and  aids  in  converting  the  residue  of  starch  into  maltose  and  dex- 
trin. The  "  wort "  thus  formed  is  a  solution  of  diastase,  dextrin, 
sugar,  proteids,  and  salts.  It  is  drawn  off,  and  the  residue  of  grain 
is  washed  with  hot  Avater  by  a  process  called  "  sparging,"  which 
extracts  any  remaining  useful  material.  The  wort  is  run  into  cop- 
per kettles  and  boiled  for  about  four  hours.  During  the  last  hour 
hop?  are  poured  in.  The  boiling  concentrates  the  wort,  extracts 
the  hop  essence  or  lupulin  with  tannin,  causes  coagulation  and  pre- 
cipitation of  any  albuminous  substance,  and  finally  it  checks  further 


STIMULANTS  AND   BEVERAGES  275 

fermentation  for  the  time  being.  The  wort  is  next  cooled  and  yeast 
is  added  in  the  proportion  of  about  a  pound  to  the  barrel.  The  yeast 
sets  up  a  new  fermentation,  which  converts  the  saccharine  substances 
into  alcohol  and  carbon-dioxide  gas.  This  fermentation  is  retarded 
by  continued  application  of  cold.  When  it  is  concluded,  the  beer 
is  drawn  into  settling  tuns,  and  then  into  casks,  where  it  is  stored  from 
five  to  eight  months,  after  which  it  is  ready  for  bottling.  While 
resting  in  the  casks  the  beer  is  subjected  to  "fining" — i.  e.,  beech- 
tree  shavings  are  added  to  it,  to  collect  any  floating  solid  particles. 
This  process  allows  so  much  carbonic  acid  to  escape  that  a  second 
fermentation  is  sometimes  set  up  by  adding  new  beer  to  the  old  in 
the  proportion  of  1  to  5. 

Beer  which  is  kept  long  fermenting  increases  in  alcohol  and 
diminishes  in  extractives.  Its  natural  intensity  of  color  varies  with 
the  method  of  drying  the  malt,  and  increases  with  long  boiling. 

White  beer  ("  Weissbier ")  is  brewed  from  wheat  instead  of  rye. 
It  is  less  clear  than  rye  beer,  paler,  and  more  frothy  and  sour. 

The  low  Bavarian  beer  is  fermented  by  a  variety  of  saccharomyces, 
which  acts  at  a  temperature  of  43°  to  46°  F. 

Certain  varieties  of  saccharomyces,  acting  at  different  tempera- 
tures, set  up  undesirable  fermentation  in  both  beer  and  wine,  mak- 
ing them  sour,  and  developing  peculiar  odors. 

Ale. —  Ale  is  made  from  pale* malt  by  processes  resembling  the 
brewing  of  beer.  It  contains  from  3  to  6  per  cent  of  alcohol. 
Strongly  alcoholic  ales  are  less  used  than  formerly,  having  been 
largely  supplanted  by  the  lighter  varieties  and  by  beer.  The  quan- 
tity of  hops  used  determines  the  bitterness  of  the  ale,  and  their 
aromatic  bitter  principles  furnish  the  peculiar  flavor.  Bitter  ale  has 
been  so  far  fermented  as  to  contain  very  little  sugar. 

Porter. —  Porter  is  made  from  pale  malt  with  the  addition  of  high 
dried  malt,  which  gives  it  color  and  flavor.  It  contains  about  6 
per  cent  of  alcohol,  and  is  regarded  as  more  digestible  than  ale  of  the 
same  alcoholic  strength.  Both  ale  and  porter  contain  sugar  and 
acid,  but  these  substances  are  present  in  less  degree  in  malt  liquors 
than  in  wines. 

Stout. —  Stout  is  similar  to  porter,  but  is  characterized  by  a  pre- 
ponderance of  extractives.  It  is  fermented  with  hop  yeast  from 
barley. 

The  stronger  malt  liquors,  such  as  porter,  stout,  and  heavy  ales, 
are  nutritive  and  fattening. 

All  stale,  flat  malt  liquors  without  a  "  head  "  are  liable  to  nauseate 
and  prove  unwholesome. 


276  STIMULANTS,   BEVERAGES,   CONDIMENTS 

Wine 

Composition. —  Wine  made  from  the  expressed  juice  of  different 
varieties  of  the  grape  consists  of  an  alcoholic  solution  varying  in 
strength  from  6  to  25  volumes  per  cent,  and  containing  flavoring 
and  other  substances. 

The  maximum  normal  percentage  of  alcohol  which  fermenting 
grapes  are  capable  of  developing  is  not  above  15  per  cent,  but  alco- 
hol is  often  added  to  equal  18  or  25  per  cent  or  more. 

The  pulp  of  the  grape  furnishes  sugar  for  fermentation  of  alcohol, 
and  also  organic  acids  or  their  salts,  such  as  citrates,  malates,  and 
tartrates.  The  stones  or  seeds  furnish  essential  oils,  some  of  which 
give  the  "bouquet"  of  volatile  ethers,  and  the  skins  and  stems  fur- 
nish pigments  and  tannin.  The  latter  is  preservative ;  it  precipitates 
albuminous  substances  and  prevents  moldiness.  The  chief  pigment 
of  wines  is  primarily  of  a  blue  color,  but  it  is  reddened,  like  litmus, 
by  free  acid,  more  or  less  of  which  is  always  present. 

The  fermentation  of  wines  is  caused  by  yeast  germs,  which  exist 
upon  the  stems  or  skins  of  the  grapes. 

Besides  water,  sugar,  alcohol,  volatile  ethers,  and  carbonic  acid  are 
added  in  the  manufacture  of  the  different  kinds  of  wine. 

Leoser  gives  the  following  list  of  minor  substances,  traces  of  which 
are  more  or  less  constantly  present  in  wines :  "  Gelatin,  gum,  fat, 
wax,  albumin,  gluten,  tartaric  acid,  potassic  tartrate,  racemic  acid, 
malic  acid,  calcic  malate,  oxide  of  manganese,  oxide  of  iron,  potassium 
sulphate,  sodium  chloride,  calcium  phosphate,  magnesia,  silicic  acid, 
tannic  acid." 

The  composition  of  the  subtle  substances  which  impart  the  flavor 
and  aroma  or  bouquet  to  different  wines  is  unknown.  Most  of  these 
substances  develop  during  fermentation,  but  a  few  grapes,  such  as  the 
Muscatel,  yield  their  own  aroma  to  the  wine. 

According  to  Konig,  the  average  percentage  composition  of  grape 
must  is  water,  74.49 ;  sugar,  19.71 ;  nitrogenous  material,  0.28 ;  non- 
nitrogenous  material,  4.48;  ash,  0.40;  acid,  0.64. 

The  grape  sugar  fluctuates  sometimes  as  much  as  24  per  cent  and 
the  acid  1.2  per  cent,  and  these  substances  usually  stand  in  inverse 
proportion  to  each  other. 

General  Properties. —  The  perfected  wine  has  the  properties  of 
color,  "  body "  or  substance,  and  flavor,  aroma,  bouquet,  or  "  fruiti- 
nese."  Different  wines  are  valued  for  their  astringency  (tannin), 
sweetness  (grape  sugar),  strength  (alcohol),  acidity  (organic  acids), 
color  or  sparkle,  flavor,  and  ability  to  stimulate  the  appetite  and 
digestion. 


STIMULANTS  AND  BEVERAGES  277 

Fermentation. —  Wines  are  both  naturally  and  artificially  fer- 
mented, and  many  varieties  are  reinforced  by  flavoring  extracts  and 
fortified  by  addition  of  alcohol.  The  latter  method  has  the  twofold 
effect  of  adding  to  their  strength  and  of  preserving  them  from  further 
fermentation,  and  hence  is  used  especially  for  the  wines  of  the  Cape, 
Madeira,  and  Portugal.  In  the  cooler  climate  of  France,  Germany, 
and  Hungary  fermentation  proceeds  more  slowly  and  fortification  is 
less  necessary,  for  the  wines  of  these  countries  are  drier  (i.  e.,  less 
sweet),  less  fruity,  and  require  less  time  to  mature.  They  also  have 
stronger  bouquet,  because  they  possess  more  acid,  which  combines  with 
alcohol  to  furnish  the  aroma  (Pavy). 

Sugar. —  The  quantity  of  sugar  present  in  wines  varies  consider- 
ably. It  is  sometimes  almost  completely  eliminated  by  fermentation 
into  alcohol,  or  it  may  be  added  in  excess  to  make  the  natural  flavor 
sweeter. 

Flavor  and  Bouquet. —  Some  Greek  wines  have  a  peculiar  flavor, 
the  liking  for  which  is  an  acquired  taste.  This  flavor  is  derived  from 
rosin  contained  in  the  wood  of  casks  used  for  preserving  the  wines, 
which  induces  chemical  changes. 

The  Hungarian  wines  possess  agreeable  fruitiness,  but  are  not  so 
completely  ripened  as  French  wines,  and  are  hence  likely  to  turn  sour 
when  transported. 

Both  glucose  and  saccharose  may  be  oxidized  into  acids  instead  of 
fermenting  to  alcohol,  and  when  this  process  occurs  extensively  in  a 
wine  it  becomes  sour,  like  vinegar,  and  unfit  for  consumption. 

In  general  the  flavor  and  bouquet  of  a  wine  depend  upon  (1)  the 
nature  of  the  soil  in  which  the  grape  is  grown,  (2)  the  climate  and 
temperature,  (3)  the  quality  of  the  grape,  (4)  the  use  of  only  a  single 
variety  of  grape  for  a  given  wine,  (5)  the  ripeness  of  the  grape,  (6) 
the  duration  of  fermentation,  (7)  the  addition  or  subtraction  of  ma- 
terial by  the  art  of  the  wine  grower,  (8)  the  age  of  the  wine. 

In  vineyards  where  the  best  wines  are  made  the  grapes  are  tested 
from  day  to  day  to  determine  the  right  time  to  pick  the  vines,  for  the 
quantity  of  sugar  and  acid  present  depend  upon  the  degree  of  ripen- 
ing and  influence  the  flavor  of  the  wine. 

White  Wines. —  White  wine  is  made  from  grapes  of  any  color, 
the  greatest  care  being  taken  not  to  macerate  the  berries  in  express- 
ing the  juice,  and  to  allow  no  colored  juice  to  flow.  As  a  rule,  how- 
ever, the  better  class  of  white  wines  is  made  from  selected  white 
grapes,  which  are  crushed  with  their  skins.  The  mass  is  left  for 
several  days,  so  that  the  skins  may  impart  what  little  soluble  matter 
they  contain  to  the  pulp.  The  juice  is  then  obtained  by  further  pres- 


278  STIMULANTS,   BEVERAGES,   CONDIMENTS 

sure  and  allowed  to  ferment.  The  crushing  of  grapes  was  formerly 
done  by  the  feet  of  men  who  trampled  upon  them,  but  several  lives 
were  lost  by  carbonic-acid  gas  poisoning,  and  -the  process  is  now  gen- 
erally conducted  by  machinery. 

After  several  months,  or  longer,  the  ferment  and  the  salts  which 
are  insoluble  settle  in  a  sediment  called  lees,  and  the  supernatant  fluid 
is  carefully  drawn  off  and  casked  or  bottled. 

During  the  first  year  or  so  of  storage  some  wines  are  recasked  sev- 
eral times,  for  they  continue  to  deposit  lees  on  the  bottom  and  sides 
of  the  cask,  consisting  mainly  of  "argol,"  an  acid  salt  from  which 
cream  of  tartar  may  be  prepared. 

When  fermentation  has  proceeded  long  enough  it  is  stopped,  accord- 
ing to  the  nature  of  the  wine,  by  the  addition  of  alcohol  or  strong 
sugar  solution,  or  if  left  to  continue  after  the  wine  is  stored,  the 
sugar  and  extractives  very  gradually  disappear,  and  alcohol  continues 
to  develop.  Hence,  if  a  wine  can  be  bottled  early  without  being  too 
green  or  immature  it  is  sometimes  a  decided  advantage,  for  more  of 
the  aroma 'and  flavor  may  thus  be  retained. 

In  other  cases  wines  should  remain  in  the  casks  for  from  one  to 
four  years  before  bottling  —  the  more  delicate  varieties  being  kept 
the  longest  —  for  certain  changes  depend  upon  the  size  and  nature  of 
the  containing  receptacle,  which  are  checked  by  bottling. 

White  wines  are  produced  in  more  variety  than  red  wines.  On  the 
average  they  contain  from  9  to  12  per  cent  of  alcohol,  from  0.30  to 
0.50  per  cent  of  sugar,  and  about  0.50  per  cent  of  acid. 

Red  Wines. —  In  making  red  wine  dark  grapes  are  used,  and  both 
skins  and  stones  are  left  to  ferment  with  the  pulp,  to  which  they  fur- 
nish tannin,  pigment,  and  extractives. 

Eed  wines,  on  the  average,  contain  from  8.5  to  11  per  cent  of  alco- 
hol, 0.55  to  0.65  per  cent  of  acid,  and  0.15  to  0.20  per  cent  of  tannin 
and  pigment.  The  red  wines  are,  as  a  rule,  more  easily  digested  than 
white,  and  are  more  nutritive. 

The  following  practical  statements  are  quoted  from  Leoser : 

"  Bottled  red  wines  that  are  rich  in  tannic  acid,  like  port,  for  in- 
stance, deposit  a  sediment  and  grow  lighter  in  color.  Those  that 
contain  less  tannic  acid  generally  grow  darker.  The  cause  of  this  is 
a  gradual  diminution  in  the  quantity  of  free  acid  in  the  wine.  The 
effect  of  this  acid  is  to  turn  the  coloring  matter  red,  and  as  it  dimin- 
ishes, therefore,  the  wine  grows  darker  or  more  purple." 

Red  wine  (claret)  is  often  drunk  diluted  with  Vichy,  when  "the 
potassium  carbonate  of  the  water  saturates  the  free  acid  of  the  wine, 
and  so  destroys  the  red  color  and  permits  it  to  become  darker,  while 


STIMULANTS  AND  BEVERAGES  279 

the  action  of  the  alkali  upon  the  coloring  matter  gives  it  a  cloudy 
appearance/' 

The  deeper  the  color  the  rougher  is  the  flavor  of  the  wine  in  most 
cases. 

"  If  two  wines  of  equal  alcoholic  strength  be  taken  it  will  be  found 
that  equal  doses  of  each  will  produce  their  effect  much  more  quickly 
in  the  case  of  the  white  wine  than  in  that  of  the  red.  The  reason  of 
this  is  that  the  astringent  action  of  the  tannic  acid  retards  the  effect 
of  the  alcohol  upon  the  organism.  It  may  be  that  this  indicates  in 
a  general  way  the  superiority  of  white  wines  as  stimulants  and  red 
wines  as  tonics." 

Various  substances  are  used  for  "  fining  " —  that  is,  to  clarify  wine 
—  such  as  cream,  milk,  blood,  solutions  of  egg  albumen,  gelatin, 
isinglass,  nutgalls,  lime,  etc.  Their  effect  is  largely  mechanical,  but 
the  alkalies  neutralize  part  of  the  acids. 

Other  substances  are  occasionally  employed,  having  in  view  the 
better  preservation  of  wine,  but  many  of  these  are  unhealthful  in 
their  effects  on  the  system.  Such,  for  example,  is  the  use  of  calcium 
sulphate,  which  is  converted  into  potassium  sulphate,  or  the  use  of 
alum,  sulphuric  or  other  acids,  etc.  Impure  alcohol  holding  fusel 
oil  is  sometimes  added.  The  object  of  storing  wine  in  enormous 
tuns  is  to  diminish  the  surface  exposed  to  the  air  in  comparison  with 
the  bulk. 

THE   VARIETIES   OF   WINES 

The  following  classification  of  wines,  with  the  examples  and  com- 
ments, is  largely  derived  from  Chambers,  and  will  be  found  convenient 
and  practical  from  a  purely  dietetic  standpoint. 

Wines  may  be  classed  as  — 

I.  Strong  Dry  Wines.  II.  Strong  Sweet  Wines.  III.  Aromatic 
Wines.  IV.  Acid  Wines.  V.  Sparkling  Wines.  VI.  Perfect 
Wines.  VII.  Rough  or  Astringent  Wines. 

I.  Strong  Dry  Wines  are  those  in  which  the  sugar  of  the  ex- 
pressed grape  juice  or  "must"  has  fermented  into  alcohol,  either 
by  process  of  time  or  by  artificial  means.  When  left  to  itself,  this 
alcoholic  fermentation  is  extremely  slow,  occupying  many  years  before 
its  completion,  but  the  natural  process  is  better  than  any  artificial  one 
yet  discovered.  These  wines  also  contain  considerable  alcohol,  often 
17  or  18  per  cent,  which  makes  them  less  available  for  general  dietetic 
uses  than  weaker  wines.  Examples  are  strong,  dry  old  sherry,  port, 
Madeira,  and  Johannisberg.  (The  name  "sherry"  is  often  used  as 
a  generic  term  for  white  wines  grown  in  Spain. 


280 

These  wines,  especially  sherry,  are  sometimes  used  for  stimulation 
in  fevers  or  other  diseases,  in  lieu  of  spirits,  where  the  taste  of  the 
latter  is  strongly  disliked.  If  drunk  too  freely  they  congest  the 
stomach,  and  have  the  evil  effects  of  strong  spirits  or  of  strong  alcohol 
in  general.  (See  Alcohol,  evil  effects,  p.  264.)  They  often  contain 
sugar,  and  taken  with  meals  may  cause  acetic  fermentation,  especially 
disturbing  the  digestion  of  fats. 

Port  is  a  wine  in  which  the  original  fermentation  has  been  arrested 
by  addition  of  alcohol,  and  it  has  a  proverbially  bad  reputation  for 
precipitating  attacks  of  gout. 

It  is  well  known  that  port  improves  more  by  long  rest  in  the  bottle 
than  does  any  other  wine  except  Madeira.  It  is  a  useful  temporary 
tonic,  and,  like  claret,  its  astringency  makes  it  serviceable  in  diarrhceal 
diseases,  but  many  persons,  especially  in  this  country,  find  it  alto- 
gether too  heavy  for  daily  use.  This  is  not  altogether  due  to  its  high 
percentage  of  alcohol,  for  a  greater  quantity  of  strong  spirits  will 
sometimes  be  found  to  do  less  damage.  It  is  a  poor  wine  for  dys- 
peptics, and  should  be  proscribed  in  all  bilious  states,  lithiasis,  cases 
with  tendency  to  gallstone  formation,  gravel,  gout,  and  rheumatism. 
It  has  largely  been  replaced  of  late  years  as  a  dinner  wine  by  other 
wines. 

Port  as  well  as  Burgundy  is  sometimes  spiced  or  "  mulled,"  and 
prescribed  diluted,  as  a  tonic  for  elderly  people.  .Taken  before  retir- 
ing, with  a  biscuit,  or  mixed  with  a  light  gruel,  it  may  promote  their 
sleep. 

II.  Strong  Sweet  Wines  are  those  which  contain,  either  natural 
or  artificially  added,  fruit  sugar  in  sufficient  quantity  to  exercise  a 
preservative  influence,  and  further  fermentation  is  checked  by  boiled 
grape  juice.  Examples  are  Tokay,  Malaga,  sweet  sherry,  sweet  cham- 
pagne, Malmsey,  sweet  Madeira,  Lachrymse  Christi,  and  other  vins 
de  luxe.  They  are  much  too  sweet  to  be  drunk  in  quantity,  but  this 
quality  is  sometimes  made  to  disguise  the  bitterness  of  other  sub- 
stances, as  when  Tokay  is  added  to  cocoa  extract  to  make  "  wine 
of  cocoa."  If  long  kept,  the  sweetness  is  reduced  but  the  peculiar 
agreeable  flavor  remains.  Alcohol  may  be  added  to  further  insure 
preservation  and  increase  the  strength  of  the  wine,  and  sweet  port  is 
sometimes  made  in  this  manner. 

The  sweet  heavy  wines,  such  as  sweet  port,  sherry,  and  Madeira, 
contain  about  19  to  22.5  per  cent  of  alcohol,  3.5  to  6  per  cent  of  sugar, 
and  about  0.50  per  cent  of  acid.  Malaga  and  Tokay  contain  more 
sugar  and  less  alcohol. 

The  chief  use  of  these  wines  is  for  their  agreeable  flavor.     They  are 


STIMULANTS   AND   BEVERAGES  281 

better  taken  between  meals,  if  at  all,  both  because  the  delicacy  of 
their  flavor  is  more  appreciated  when  the  mouth  is  free  from  other 
tastes  and  because  their  sweetness  may  interfere  with  digestion.  Like 
all  sweet  wines,  they  must  be  forbidden  to  the  gouty,  rheumatic, 
bilious,  lithsemic,  and  dyspeptic. 

III.  Aromatic  Wines  have  a  peculiarly  choice  bouquet,  and  con- 
tain abundance  of  essential  oils  with  considerable  alcohol.     They  are 
best  when  drunk  in  their  native  countries  —  in  Spain,  France,  Italy, 
etc. —  for  they  bear  transportation  poorly  unless  reinforced  by  ad- 
ditional alcohol,  which  detracts  from  their  delicacy  of  flavor  and 
aroma.     Examples  are  the  choicer  Ehine  wines,  Moselle,  Capri,  Cha- 
teau-Yquem,  and  Orvieto.    Some  wines  of  this  class  are  "  more  noted 
for  their  acid  than  aroma "  (Chambers).     Such  are  white  Burgundy 
(Chablis)   and  white  Bordeaux   (Sauterne),  which  are  often  drunk 
with  salads  and  rich  foods.     The  Moselle  and  Ehine  districts  produce 
acid  grapes  with  abundant  aroma,  and  the  wines  which  bear  these 
names  are  many  of  them  almost  free  from  sugar. 

IV.  Acid  Wines  owe  their  distinguishing  property  to  tartaric  acid 
chiefly,  but  wines  which  have  turned  sour  on  keeping  or  by  exposure 
to  the  air  contain  acetic  acid  and  resemble  vinegar. 

V.  Sparkling  Wines  are  thpse  in  which  carbon-dioxide  gas,  formed 
by  fermentation  after  the  wine  is  bottled,  is  set  free  upon  uncorking, 
and  continues  to  be  liberated  for  sometime  thereafter.     The  gas  im- 
parts additional  flavor  to  the  wine  and  increases   its   exhilarating 
effect.     Such   wines   are   champagnes,   sparkling   Moselle,   and   vino 
d'Asti.     The  better  the  wine,  the  longer  it  continues  to  give  off  gas 
and  aroma  after  uncorking.     Good  champagne  is  bottled  under  a  pres- 
sure of  about  five  atmospheres. 

These  wines,  especially  good  champagne,  are  very  serviceable  for 
invalids,  and  some  persons  with  delicate  stomachs  can  digest  no  other 
form  of  alcohol;  but  poor  champagne  causes  gastric  derangement 
sooner  than  any  other  wine. 

When  nausea  and  vomiting  exist  they  have  special  power  for  allay- 
ing the  gastric  irritation.  They  are  absorbed  with  great  rapidity, 
and  act  promptly  by  invigorating  the  nervous  system  and  circulation. 
They  may  sometimes  be  substituted  for  spirits  in  fevers  when  there 
is  need  of  alcoholic  stimulation.  Their  cost,  unfortunately,  places 
them  out  of  the  reach  of  many,  and  it  also  affords  much  tempta- 
tion for  adulteration. 

CHAMPAGXE. —  The  essential  difference  between  champagne  and 
the  non-effervescing  wines  is  that  it  contains  carbon-dioxide  gas  in 
solution. 


282  STIMULANTS,   BEVERAGES,   CONDIMENTS 

Manufacture. —  Champagne  is  made  of  different  grades,  represent- 
ing the  first,  second,  and  third  expressing  of  the  grape  juice  re- 
spectively. It  contains  approximately  12  per  cent  of  alcohol,  or 
less. 

Good  champagne  is  made  as  follows:  The  juice  is  allowed  to 
ferment  for  about  two  weeks,  when  it  is  poured  into  casks  and  kept 
for  a  period  varying  from  two  to  six  months,  after  which  it  is  bottled 
and  kept  from  two  to  nine  years  in  racks  arranged  to  hold  the  bottles 
with  their  mouths  down,  so  that  on  opening  them  all  sediment  which 
has  collected  in  their  necks  can  be  removed  or  "  disgorged."  The 
final  process  is  the  addition  of  sugar-candy  sirup  dissolved  in  old 
wine  and  white  cognac  brandy.  For  the  "  sec  "  brand  8  per  cent  of 
sirup  is  added ;  for  other  brands  varying  quantities  up  to  16  per  cent 
are  poured  in.  A  little  alcohol,  too,  may  be  added,  after  which  the 
wine  is  again  corked,  and  left  standing. 

French  champagnes  sometimes  have  liqueurs  or  cordials  added  for 
flavoring,  but-  American  champagnes  depend  solely  upon  the  grape 
flavor. 

Dry  ness. —  Much  emphasis  is  placed  on  the  value  of  "  dry  "  cham- 
pagne for  invalids,  which  means  that  the  sugar  which  it  originally 
contained  has  disappeared,  and  hence  the  wine  is  less  likely  to  produce 
flatulent  dyspepsia  or  aggravate  conditions  in  which  saccharine  food 
is  harmful.  True  "  dryness  "  is  the  result  of  age,  and  is  due  to  a 
very  slow  conversion  of  sugar  into  alcohol,  such  as  goes  on  in  port 
wine  which  has  been  kept  for  several  decades,  but,  as  pointed  out  by 
Chambers,  this  process  of  slow  ripening  does  not  remunerate  the 
dealer,  so  he  induces  a  quicker  acetous  fermentation  by  which  all  the 
sugar  is  transformed  in  a  few  months,  instead  of  many  years,  or  else 
he  puts  only  half  the  quantity  of  sirup  into  the  wine  —  4  instead  of 
8  per  cent.  It  is  champagne  manufactured  in  this  manner  which  is 
usually  shipped  out  of  France  for  foreign  consumption,  and  hence 
this  wine  often  has  a  "  dry  "  taste  because  it  is  sour,  and  not  because 
it  is  wholly  free  from  sugar.  When  this  is  the  case,  it  imparts  a 
bright  red  color  to  blue  litmus,  after  the  free  carbonic  acid  which  it 
contains  has  been  allowed  to  escape.  The  various  brands  called  "  dry," 
"  extra  dry,"  or  "  sec,"  "  ires  sec,"  usually  represent  only  varying  de- 
grees of  acidity.  "  Brut "  refers  to  wines  left  to  undergo  natural  fer- 
mentation. 

YL  "  Perfect "  Wines  are  those  which  are  classified  by  Cham- 
bers as  having  their  several  ingredients — "alcohol,  water,  sugar, 
ethereal  flavors,  fruity  extractives,  and  acids" — commingled  without 
giving  characteristic  prominence  to  either  one.  Such  are  many  of 


STIMULANTS  AND  BEVERAGES  283 

the  best  clarets,  but  the  red  wines  usually,  from  one  cause  or  another, 
fall  under  some  other  class. 

Bordeaux,  Burgundy. —  The  best  Bordeaux  is  fully  fermented,  but 
the  commoner  Burgundies  and  red  Khones  contain  "  too  much  fruity 
extractive,  which  decomposes  unless  reinforced  by  alcohol,  and  are 
unwholesome  unless  ripe  when  drunk"  (Chambers).  When  a  red 
wine  is  so  decomposed  it  is  unfit  for  consumption.  Ee-fermentation 
in  it  may  be  discovered  by  lightly  corking  a  half -filled  bottle,  letting  it 
stand  for  some  hours  in  a  warm  place,  and  then  shaking  it.  If  car- 
bonic acid  is  present,  it  will  rise  in  bubbles  and  expel  the  cork.  Wine 
of  this  sort  deranges  digestion,  causing  acid  eructations  and  gastric 
discomfort. 

Prime  Burgundies,  on  the  contrary,  like  Chambertin,  have  more 
"  body,"  and,  because  they  contain  a  larger  percentage  of  alcohol,  do 
not  ferment.  Moleschott  gives  the  average  volumetric  percentage  of 
alcohol  in  red  wines  as  follows :  Clarets  or  red  Bordeaux,  10.61 ;  red 
Ehone,  10.39;  red  Burgundy,  11.19. 

Therapeutic  Uses. —  Prime  clarets,  Bordeaux,  and  Burgundies  are 
useful  tonics  for  invalids,  to  be  given  in  moderation  with  meals,  or 
in  some  cases  with  a  biscuit  or  light  sandwich  as  a  luncheon  between 
meals.  They  contain  little  or  no  sugar,  and  are  of  excellent  service 
in  convalescence 'from  protracted  fevers,  such  as  typhoid,  or  from  the 
grippe,  etc.  The  lighter  forms,  if  of  good  quality,  are  the  best  form 
of  wine  for  daily  consumption  by  brain  workers  or  those  whose  seden- 
tary habits  or  whose  advanced  age  make  desirable  a  slight  stimulus 
to  appetite  and  digestion.  Claret  is  almost  the  only  wine  which  it  is 
at  all  safe  to  allow  gouty  or  diabetic  patients. 

Beaujolais  is  intermediate  in  effect  between  claret  and  Burgundy. 

In  diarrhoea,  the  red  wines,  according  to  Lichtenstern,  have  a  two- 
fold beneficial  action :  first,  by  depressing  exalted  reflex  excitability  in 
visceral  nerves,  and,  secondly,  by  controlling  intestinal  putrefaction. 
Those  which  contain  considerable  tannin  are  also  mildly  astringent. 

VII.  Rough  Wines  are  those  in  which  an  excess  of  tannin  causes 
decided  astringency.  They  usually  contain  pigment,  but  not  much 
alcohol.  Some  clarets  belong  with  this  group. 

As  a  rule,  these  wines  are  not  available  for  general  dietetic  or 
invalid  use,  and  are  mainly  employed  to  add  to  other  wines  to  aid 
in  their  preservation  and  otherwise  alter  them,  although  they  are 
sometimes  drunk  by  peasants  in  the  countries  in  which  they  are 
produced. 

Concentrated  Wines. —  Attempts  to  concentrate  wines  by  heat 
evaporation  of  the  water  contained  in  them  result  in  the  loss  of  the 


284 


STIMULANTS,    BEVERAGES,    CONDIMENTS 


ingredients  which  furnish  "bouquet"  or  "aroma,"  and  which  are 
more  volatile  than  the  alcohol.  A  process  has  been  devised  in  France 
by  which  concentration  is  secured  by  cold  without  this  loss.  In  con- 
gealing to  ice  the  water  does  not  include  the  volatile  ingredients  of  the 
wine.  The  wine  is  submitted  to  a  temperature  below  freezing,  the 
ice  meanwhile  being  mechanically  broken  into  minute  particles,  which 
are  then  separated  by  a  centrifugal  machine.  The  result  is  a  wine 
composed  of  uncongealed  concentrate  and  condensed  to  from  60  to 
80  per  cent  of  its  original  bulk,  thereby  improving  its  capacity  for 
preservation  and  greatly  lessening  cost  of  storage  and  transporta- 
tion. The  same  ingenious  process  has  beeen  applied  successfully  to 
milk  and  fruit  juices.  Upon  addition  of  water  the  original  bulk  and 
degree  of  flavor  is  restored. 

Raisin  Wine. —  An  inferior  quality  of  wine  is  made  by  restoring 
the  water  of  the  grapes  which  has  been  lost  by  drying  them  into 
raisins.  Wine  is  now  sometimes  made  in  France  from  raisins  dried 
in  California. 

Influence  of  Wines  upon  Digestion. —  Eoberts  determined  the  ef- 
fect of  several  wines  upon  peptic  digestion  by  adding  together  two 
grams  of  dried  beef-fiber,  .0.15  per  cent  of  hydrochloric  acid,  1  c.  c. 
of  glycerin  extract  of  pepsin,  varying  proportions  of  hock,  claret,  or 
champagne,  and  water  to  100  c.  c. 


PROPORTION  OF  HOCK,  CLARET, 
OR  CHAMPAGNE  IN  THE  DI- 
GESTING MIXTURE. 

TIME  IN  WHICH  DIGESTION  WAS  COMPLETED. 
(NORMAL,  100  MINUTES.) 

Hock. 

Claret. 

Champagne. 

10  per  cent  

100  minutes. 
115 
150 
Embarrassed. 

100  minutes. 
140 
180          " 
Embarrassed. 

90  minutes. 
100 
130 
180          " 

20     "       "          

40     "       "          

60     "       "          

Liquors 

Strong  spirits,  such  as  rum,  whisky,  brandy,  and  gin,  are  the  worst 
forms  of  alcohol  for  daily  drinking,  and  liquors  of  this  class  are  re- 
sponsible for  nine-tenths  of  the  evils  of  inebriety.  As  the  system  re- 
quires toleration  for  the  stronger  forms  of  liquor,  it  is  found  that  its 
desired  effects  only  can  be  obtained  by  constantly  increasing  the 
strength  or  frequency  of  the  drinks,  and  meanwhile  the  alcohol  ab- 
sorbed is  gradually  converting  the  different  tissues  of  the  body  into 
pathological  specimens. 

The   drinking  of  new  and  raw  liquors   is  particularly   injurious, 


STIMULANTS  AND  BEVERAGES  285 

for  time  mellows  them  somewhat  and  reduces  the  quantity  of  their 
most  hurtful  ingredient  —  fusel  oil  —  while  their  flavor  improves. 
The  difference  in  taste  of  liquors  depends  upon  the  substances  from 
which  they  are  made  much  more  than  upon  any  skill  in  their  manu- 
facture or  modifications  in  their  fermentation,  circumstances  which 
so  materially  affect  wines.  The  taste  varies  with  the  relative  quan- 
tity present  of  aldehyde,  compound  ether,  higher  alcohol  (fusel  oil), 
and  volatile  bases. 

Brandy  and  other  strong  spirits  are  distilled  from  a  variety  of 
carbohydrate  foods:  such  are  potatoes,  corn,  rye  (whisky),  beets, 
rice  (arrack  and  sake),  molasses  (rum),  crushed  grapes,  apples 
(applejack),  peaches,  plums,  cherries  (Kirsch),  and  other  fruits. 
These  spirits  contain  from  45  to  60  per  cent  of  alcohol,  besides  cane 
sugar  and  extractives. 

French  Cognac  is  a  strong,  pure  brandy,  distilled  either  from  wine, 
or  directly  from  crushed  grapes.  It  may  be  colored  by  caramel. 
Common  brandy  is  distilled  from  wine. 

Whisky. —  American  whiskies  are  classed  as  (1)  rye  and  (2)  Bour- 
bon, from  the  county  of  that  name  in  Kentucky. 

Manufacture. —  The  percentage  of  materials  used  in  making  the 
"  mash  "  for  distillation  is,  on  the  average,  cornmeal  80,  rye  10,  and 
malt  10.  This  mixture  is  placed  in  tubs,  and  scalded  with  "  slop," 
the  refuse  from  former  distillation.  After  cooling,  it  is  raked,  or 
mixed  by  a  stick  called  a  "masher."  Water  is  added,  and  the  mass 
ferments  for  two  or  three  days. 

Sweet  mash  is  scalded  with  water  instead  of  slop,  and  yeast  is  added 
to  induce  fermentation. 

Sour-mash  whisky  is  made  without  yeast  but  with  slop.  The  wort 
is  then  heated  by  steam,  and  the  low  wines,  called  "  singlings,"  are 
run  off  from  the  residue  or  slop  and  redistilled,  and  the  whisky  is 
ready  for  barreling.  It  should  then  be  kept  from  three  to  five  years 
to  ripen,  according  to  the  details  of  its  manufacture. 

Pure  rye  whisky  is  distilled  by  an  identical  process,  but  the  corn 
is  wholly  replaced  by  rye. 

Scotch  and  Irish  whiskies  are  distilled  from  a  barley  mash. 

American  whiskies  are  kept  in  charred  barrels,  and  grow  darker 
from  color  derived  from  the  wood.  Scotch  whisky  derives  its  color 
from  lying  in  old  sherry  casks. 

Proof  spirit  contains  equal  parts  of  absolute  alcohol  and  water. 

Leoser  says :  "  The  difference  in  quality  in  different  kinds  of 
whisky  is  infinitesimal,  and  for  therapeutic  processes  may  be  neg- 
lected, provided  the  taste  of  the  patient  is  consulted." 


286  STIMULANTS,   BEVERAGES,   CONDIMENTS 

The  evil  effects  of  poor  whisky  are  largely  due  to  the  presence  in 
excess  of  a  regular  constituent,  an  aldehyde  called  furfural. 

Gin  is  distilled  from  rye  mash,  and  flavored  by  immersing  a  bag 
of  juniper  berries  in  the  vat  towards  the  completion  of  distillation. 

It  is  variously  known  under  the  names  Geneva,  Hollands,  and 
Schiedam,  the  two  latter  referring  to  its  Dutch  source,  the  former 
being  derived  from  the  French  word  for  juniper,  genievre,  of  which 
gin  is  a  corruption  (Pavy).  Gin  may  contain  17  per  cent  of  alcohol, 
but  it  is  often  diluted,  and  when  sweetened  besides,  it  is  known  as 
"  Old  Tom." 

Rum  is  distilled  from  a  mash  of  molasses.  The  wort  contains 
about  15  per  cent  of  sugar,  and  the  fermentation  process  requires 
from  nine  to  fifteen  days.  Eum  was  formerly  made  in  New  England, 
but  it  now  comes  chiefly  from  the  West  Indies,  and  that  made  in 
Jamaica  is  considered  the  best.  Other  rum  is  made  from  rectified 
proof  spirit.  It  is  a  liquor  which  improves  very  much  on  keeping 
for  several  years.  The  flavor  of  rum,  which  is  principally  due  to 
butyric  ether,  is  produced  by  adding  molasses,  caramel,  and  some- 
times fruits,  such  as  pineapple  or  guava.  Acetic  and  other  ethers  are 
also  present. 

Therapeutic  Uses  of  Liquors  Compared. —  The  spirits  in  common 
use  have  different  physiological  action.  As  their  alcoholic  basis  is 
substantially  the  same  in  quality,  the  effects  are  varied  mainly  by 
aromatics.  Gin  is  the  most  distinctly  diuretic  of  the  liquors.  Given 
with  a  little  lemon  juice  and  diluted  with  some  effervescing  water, 
it  promptly  increases  the  urinary  secretion.  Brandy  is  somewhat 
more  astringent  than  whisky,  which  is  sometimes  laxative.  Brandy 
is  therefore  to  be  preferred  in  cases  of  diarrhoea,  but  in  this  country 
at  least  it  is  very  likely  to  be  impure.  The  role  of  liquors  as  tonics 
and  stimulants  will  be  referred  to  under  the  heading  of  the  jdifferent 
diseases  in  which  they  may  be  required,  and  their  influence  in  pro- 
ducing alcoholism  is  discussed  under  that  heading. 

ADULTERATION    OF    LIQUORS    AND    WINES 

Liquors  are  flavored  and  also  adulterated  by  a  variety  of  substances. 
Among  those  mentioned  by  Chambers  as  oftenest  found  are  cocculus 
indicus,  ginger,  quassia,  wormwood,  caraway  and  coriander  seeds, 
hartshorn  shavings,  nux  vomica,  gentian,  alum,  cream  of  tartar, 
chamomile,  juniper  berries,  bitter  almonds,  orange  peel,  licorice, 
honey,  rhatany,  and  catechu. 

Much  of  the  cheapest  claret  sold  in  this  country  is  little  more  than 
a  decoction  of  logwood,  and  the  flavor  of  some  of  the  better  grades 


STIMULANTS   AND   BEVERAGES 


287 


is  cleverly  imitated.  For  example,  Chateau-Latour  is  sophisticated 
with  almonds  or  other  nuts,  Chateau-Lafitte  with  violets  and  nuts, 
and  to  other  grades  cherry  juice  is  added.  Wines  are  often  adul- 
terated with  artificial  pigments,  alum,  tannin,  fusel  oils,  cider,  perry, 
and  lime  salts. 

The  cheaper  grades  of  strong  liquors  contain  an  excess  of  fusel 
oil  or  amylic  ether,  which  is  not  an  adulterant  in  the  sense  that  it  has 
been  added  for  sophistication,  but  because  it  is  a  poisonous  natural 
product  which  is  difficult  to  eliminate.  It  is  responsible  for  much  of 
the  headache,  foul  tongue,  nausea,  dyspepsia,  and  cirrhotic  changes 
in  the  viscera  which  are  incident  to  dram  drinking. 

The  following  table  by  Duckworth  is  a  convenient  summary  of  the 
average  percentages  of  alcohol  in  round  numbers  in  the  different 
beverages  above  described : 


Spirits     35  to  44  per  cent. 

Port   wine    -19     " 

Madeira    18     " 

Sherry     17 

Champagne     11     " 

Burgundy     10     " 


Bordeaux     8  per  cent. 

Rhine   wines    8     "      " 

Porter    6  per  cent,  or  more. 

Ale    3  to  6  per  cent. 

Cider    4  per  cent. 


Liqueurs  and  Cordials 

Liqueurs  and  cordials  play  no  part  in  invalid  diet.  With  the  ex- 
ception of  absinthe  and  Angostura,  they  contain  a  very  high  percent- 
age of  sugar  with  essence,  and  they  all  have  a  large  proportion  of 
alcohol.  They  are  used  as  luxuries,  and  are  seductive  beverages,  for 
their  agreeable  flavor  sometimes  begets  the  habit  of  alcoholism.  This 
is  specially  the  case  with  absinthe. 

Analysis  of  Liqueurs    (Rupp) 


100  C    C.  LIQUEUR 

ALCOHOL. 

Extracts. 

Sugar. 

Salt. 

Volume. 

Weight. 

Absinthe    

Per  cent. 
55.0 
40.0 
32.5 
35.0 
48.0 
52.5 
53.0 
44.0 

Percent. 
44.0 
32.0 
26.0 
28.0 
38.4 
42.0 
42.4 
35.2 

Grains. 
1.80 
33.20 
29.80 
44.00 
12.00 
27.90 
35.00 
35.40 

Grams. 
1.10 
30.90 
28.20 
43.20 
7.50 
26.50 
33.40 
34.00 

Grams. 
0.220 
0.310 
0.100 
0.090 
0.140 
0.075 
0.110 
0.091 

Anise    

Kummel     

Peppermint   

Angostura    

Curac.oa                  .    ... 

Benedictine    

Chartreuse    

The  essences  are  distilled  or  expressed  from  aromatic  plants,  and 
such  coloring  agents  are  used  as  saffron,  cochineal,  indigo,  etc. 


288  STIMULANTS,   BEVERAGES,   CONDIMENTS 

Anisette  is  distilled  from  aniseed,  curaqoa  from  orange  rind, 
menthe  from  peppermint,  maraschino  from  small  cherries,  grown  es- 
pecially in  Dalmatia.  Chartreuse  was  formerly  distilled  from  a 
variety  of  herbaceous  plants  grown  in  the  convent  gardens  by  the 
monks  of  the  Grand  Chartreuse,  who  since  their  expulsion  from 
France,  have  transferred  the  industry  to  Tarragona.  Vermouth  is  a 
white  muscat  wine  made  aromatic  with  extracts  of  herbs  and 
spices,  sweetened  with  10  to  15  per  cent  of  sugar  and  fortified 
with  grape  alcohol  up  to  17  per  cent.  It  is  manufactured  in  Pied- 
mont. 

Fig  wine  is  made  in  countries  bordering  upon  the  Mediterranean, 
and  has  an  alcoholic  strength  of  between  7  and  8  per  cent.  It  also 
contains  considerable  mannite.  It  is  often  used  for  the  sophistication 
of  grape  wines. 

Cider. —  Cider  made  from  ripe  apples  usually  contains  from  4  to 
8  volumes  per  cent  of  alcohol  besides  malic  acid,  extractives,  sugar, 
and  salts.  It  is  slightly  laxative  and  diuretic  and  constitutes  a  whole- 
some beverage.  The  excess  of  carbonic  acid  generated  by  cider  pro- 
tects it  from  the  atmospheric  air,  but  when  the  gas  disappears  acetic 
fermentation  converts  the  cider  into  vinegar.  It  may  be  preserved 
for  a  year  or  two  by  being  surcharged  with  carbonic-acid  gas  under 
pressure.  It  is  then  known  as  "  champagne  cider/' 

Cider  is  sometimes  made  from  condensed  apple  juice,  which  is 
added  in  the  proportion  of  one  part  to  twenty  of  water  when  ready 
for  use. 

"  Hard  cider  "  is  derived  by  natural  fermentation  of  the  sugar  in 
apples.  Yeast  fungi,  which  grow  upon  the  surface  of  the  apples, 
convert  the  sugar  into  alcohol,  which  may  become  as  strong  as  6  per 
cent.  Cider  drunk  to  excess  has  been  known  to  cause  peutosuria. 

CONDIMENTS  AND  SPICES 

Properties. —  Condiments  and  spices  are  substances  used  as  ad- 
juncts to  food,  and  which  in  themselves  supply  but  little  nourishment, 
their  effect  being  mainly  of  a  stimulating  character  either  to  the 
nerves  of  taste  or  secretion.  They  add  flavor  to  otherwise  insipid 
food,  and  relieve  monotony  in  diet.  Some  condiments,  such  as  mus- 
tard, contain  a  slight  amount  of  nutritious  material,  but  the  total 
quantity  of  any  of  them  which  can  be  taken  is  so  small  in  comparison 
with  the  bulk  of  the  food  that  they  hardly  may  be  said  to  subserve 
nutrition. 

Some  foods  are  themselves  so  stimulating  to  the  mucous  mem- 


CONDIMENTS  AND  SPICES  289 

brane  that  they  answer  the  double  purpose  of  food  and  condiment 
combined;  such,  for  example,  are  onions,  peppers,  and  garlic. 

In  the  mouth  condiments  produce  an  agreeable  taste,  with  an  in- 
creased flow  of  saliva,  and  the  desire  for  food  in  the  stomach  is  stim- 
ulated. They  also  increase  the  secretion  of  gastric  juice. 

Curry  powders  of  various  sorts  are  prepared  by  mixing  strong 
condiments,  such  as  Cayenne  pepper  and  ginger,  with  starchy  food 
and  tumeric. 

Uses. —  In  some  dyspeptic  conditions  of  the  stomach  accompanied 
by  retarded  digestion  and  local  sensation  of  weight  or  oppression,  or 
even  of  pain,  the  use  with  the  food  of  strong  condiments  —  such  as 
mustard,  Cayenne  pepper,  or  Tabasco  —  affords  relief  by  exciting  the 
functional  activity  of  the  stomach.  Cayenne,  in  fact,  is  a  favorite 
ingredient  of  various  dinner  pills. 

With  the  exception  of  salt,  the  use  of  which  is  fully  described  on 
page  46,  none  of  the  condiments  are  absolutely  indispensable  in  the 
sense  of  being  essential  for  prolonging  health,  but  so  accustomed  are 
all  classes  of  men  to  their  use  from  heredity  or  personal  experience 
that,  despite  the  aphorism  of  Plutarch  that  "  hunger  and  salt  should 
be  man's  only  sauce,"  without  other  relishes  the  appetite  soon 
fails. 

Harmful  Effects. —  The  use  of  some  condiments  is  likely  to  be 
abused,  and  this  is  particularly  true  of  peppers,  curry,  pickles,  and 
vinegar.  If  consumed  habitually  in  excess,  these  substances  excite 
gastric  hypersemia  and  catarrh  by  overstimulation,  and  may  disorder 
intestinal  digestion  as  well.  They  at  first  cause  more  food  to  be 
eaten  than  necessary,  and  eventually  destroy  the  appetite,  develop- 
ing chronic  dyspepsia  of  an  aggravated  type.  Persons  living  in 
tropical  climates  where  food  and  service  are  cheap  are  apt  to  lead 
indolent  lives  and  indulge  too  liberally  in  the  pleasures  of  the  table, 
and  the  overloading  of  the  stomach  tempts  them  to  add  quantities 
of  condiments  to  their  food  for  the  purpose  of  stimulating  an  already 
overworked  digestive  system.  The  heat  of  the  climate  prevents  ac- 
tive exercise,  which  in  turn  reduces  the  oxidation  processes  of  the 
assimilated  food.  The  rational  diet  for  those  not  acclimated  to  the 
tropics  should  consist  largely  of  vegetables  and  fruits,  while  nitrog- 
enous food,  strong  condiments,  spirits,  bitter  beer,  etc.,  should  be 
carefully  shunned. 

I  have  seen  one  case  of  the  ginger  habit,  in  Bellevue  Hospital,  in  a 
woman  thirty  years  of  age.  It  was  first  acquired  by  chewing  the  roots 
of  Jamaica  ginger,  and  subsequently  the  patient  drank  large  quan- 
tities of  the  beverage  sold  under  that  name,  and  ate  powdered  ginger 
21 


290  STIMULANTS,    BEVERAGES,   CONDIMENTS 

of  every  variety.     The  patient  became  maniacal  and  greatly  emaciated. 
The  symptoms  in  general  resembled  those  of  the  cocaine  habit. 

Varieties  of  Flavoring. —  Next  to  salt  (see  p.  46),  the  most  useful 
condiments  are  pepper,  mustard,  ginger,  and  vinegar,  but  much  differ- 
ence in  taste  exists  in  the  use  of  condiments,  and  their  selection  is  to 
some  extent  a  rare  characteristic.  Thus  the  Persian  prefers  his 
asafcetida,  which  no  one  else  can  tolerate;  the  Spaniard  and  Mexican 
his  garlic;  the  East  Indian  his  curry;  and  the  Frenchman  his  salad 
with  vinegar. 

From  long-continued  association  certain  condiments  appear  to 
serve  best  with  definite  foods,  and  so  accustomed  are  most  persons  to 
their  combination  that  they  cannot  easily  recall  the  one  flavor  with- 
out the  other;  thus  mustard  is  associated  with  ham,  black  pepper 
with  eggs,  red  pepper  with  raw  oysters,  vinegar  with  spinach  and 
raw  tomatoes,  etc.,  and  when  deprived  of  the  usual  relish  the  food 
tastes  insipid.  Such  details,  insignificant  as  they  may  ordinarily 
appear,  become  very  important  for  certain  classes  of  invalids  in 
whom  it  is  necessary  to  preserve  the  appetite  by  pleasing  the  palate 
in  order  that  they  may  take  food  enough  to  sustain  them.  Such 
are  cases  of  phthisis,  empyema,  and  other  forms  of  chronic  wasting 
diseases.  - 

Beef  tea  and  meat  broths,  which  become  wearisome  to  many  in- 
valids, will  be  relished  if  a  taste  of  some  savory  aromatic  herb  be 
added,  such  as  parsley,  thyme,  sage,  marjoram,  or  mint. 

Mustard  does  not  greatly  stimulate  the  gastric  secretion,  but  many 
persons  find  that  it  increases  the  appetite  somewhat,  and  it  often  pro- 
duces a  sensation  of  warmth  or  mild  burning  in  the  stomach  or  a  feel- 
ing akin  to  hunger.  It  is  used  to  advantage  in  moderation  in  salad 
dressings  or  with  cold  meat,  and  is  sometimes  serviceable  in  those 
cases  in  which  the  main  difficulty  is  a  lack  of  appetite  without  special 
enfeeblement  of  the  digestive  organs.  The  general  irritating  effect 
of  mustard  in  large  quantities  applied  to  the  skin  or  gastric  mucous 
membrane  is  well  known,  and  diluted  with  lukewarm  water  (a  tea- 
spoonfnl  of  mustard  to  a  pint  of  water)  it  constitutes  a  very  prompt 
and  valuable  emetic.  Mustard  seeds  are  sometimes  eaten  for  their 
laxative  action. 

Blade  pepper  is  the  berry  of  a  plant,  the  Piper  nigrum,  which  grows 
in  the  West  Indies,  Sumatra,  and  other  Eastern  countries.  The 
whole  berry  is  dried  and  ground  for  use. 

White  pepper  is  made  from  the  same  berry  by  previously  soaking 
off  the  outer  husk  in  water.  About  thirteen  million  pounds  of  black 
pepper  are  annually  consumed  in  the  United  States.  It  is  often 


CONDIMENTS  AND  SPICES  291 

adulterated,  and  to  avoid  deception  it  may  be  purchased  in  corns 
and  freshly  ground  at  the  table. 

Cayenne  pepper  is  not  a  true  pepper,  but  is  made  from  the  crushed 
pod  of  various  species  of  Capsicum.  It  grows  in  the  tropics,  espe- 
cially along  the  eastern  coast  of  Africa  and  in  Zanzibar. 

The  Capsicum  annuum  is  cultivated  in  this  country  for  the  making 
of  pickles  from  the  large  unripe  green  fruit. 

The  Capsicum  fasligiatum  is  a  variety  employed  medicinally,  and 
recognized  by  the  Pharmacopoeia.  Chilies  is  a  common  name  given  to 
this  pepper  in  England,  and  chili  sauce  is  an  essence  prepared  from  it. 
It  is  the  strongest  variety  of  capsicum. 

Capsicum,  called  also  Cayenne  or  red  pepper,  like  mustard,  is  a 
strong  irritant  to  both  the  skin  and  the  mucous  membrane.  Over- 
doses of  it  excite  violent  local  inflammation  and  gastroenteritis. 
Like  mustard,  it  is  doubtful  whether  capsicum  in  any  degree  pro- 
motes the  secretion  of  the  gastric  juice,  but  it  sometimes  stimulates 
a  flagging  appetite  and  produces  a  feeling  of  warmth  in  the  stomach; 
the  latter  readily  becomes  tolerant  to  increasing  doses  of  capsicum, 
and  it  is  found  that  more  and  more  is  required  by  those  who  use  it 
habitually  to  excite  the  accustomed  stimulation.  It  is  used  as  a  sub- 
stitute for  alcohol  for  dipsomaniacs,  especially  where  the  effort  is 
being  made  to  stop  drinking  abruptly.  When  chronic  alcoholic  gas- 
tritis exists,  the  stomach  digestion  is  often  improved  and  the  craving 
for  strong  liquor  may  be  relieved  by  the  tincture  of  capsicum  given 
in  doses  of  ten  or  fifteen  minims  diluted. 

The  use  of  capsium  in  health  is  far  from  necessary,  but  it  is  an 
agreeable  condiment.  It  forms  an  ingredient  of  many  dinner  pills 
which  are  taken  by  elderly  people  with  inactive  digestion  for  the  pur- 
pose of  promoting  the  appetite. 

Eed  pepper,  like  black,  is  often  adulterated.  When  pure  it  may  be 
suspended  partially  but  not  entirely  in  water.  Eed  lead  has  crim- 
inally been  used  as  an  adulterant. 

Capers  are  the  flower  buds  of  a  bush,  the  Capparis  spinosce,  which 
grows  in  Eastern  countries  bordering  on  the  Mediterranean.  They 
are  preserved  in  salt  and  vinegar,  and  are  used  for  flavoring  sauces 
for  mutton  and  other  foods.  They  contain  tannin,  volatile  oil,  yel- 
low pigment,  and  a  bitter  principle. 

Spices  are  solely  of  value  in  giving  variety  of  taste  to  the  food, 
and  hence  tempting  invalids  or  convalescents  with  lagging  appetites 
to  eat  more.  Comparatively  tasteless  food,  such  as  rice,  may  be  made 
very  attractive  by  spicing. 

For  children  the  most  useful  flavoring  substances  are  cinnamon 


292  STIMULANTS,   BEVERAGES,   CONDIMENTS 

and  ginger,  and,  although  not  a  spice,  vanilla  extract.  For  invalids 
there  may  be  added  nutmeg  and  cloves,  although  any,  agreeable  spice 
may  be  used  in  moderation,  such  as  mace  or  allspice.  Patients  who 
will  not  drink  hot  water  when  it  is  ordered  will  often  do  so  if  they 
can  steep  a  few  cloves  or  a  small  piece  of  cinnamon  in  it,  and  this 
can  rarely  do  harm.  Those  who  object  to  the  taste  of  milk  punch, 
junket,  custards,  and  simple  farinaceous  foods  will  often  take  these 
substances  when  slightly  flavored  with  a  trace  of  some  agreeable  spice. 
The  latter  as  ordinarily  used  for  flavoring  is  never  injurious.  Only 
in  large  doses  are  such  spices  as  those  above  mentioned  capable  of 
such  irritant  action  in  the  stomach  as  may  be  produced  by  curry  or 
mustard.  Several  cases  of  nutmeg  poisoning  are  recorded.  The 
symptoms  are  excessive  thirst,  vertigo,  delirium,  stupor,  epigastric 
pain,  tremor  and  twitching  and  muscular  prostration.  Toxic  effects 
have  been  produced  by  taking  a  whole  nutmeg,  ground  and  mixed  with 
hot  water. 

Ginger  is  useful  both  as  a  condiment  and  as  a  food.  It  is  the 
dried  root  of  the  Zinziber  officinale,  which  grows  in  Jamaica,  China, 
and  elsewhere.  The  rhizome  is  scraped  and  either  dried  and  pow- 
dered, or,  if  it  is  to  be  preserved,  it  is  washed  and  boiled  for  twenty- 
four  hours,  and  then  soaked  for  another  day  in  salt  water.  It  is  next 
washed,  sun-dried,  and  "boiled  for  half  a  day  with  an  equal  weight  of 
sugar  (Clark).  It  is  placed  in  jars  for  several  days,  and  then  once 
more  boiled,  when  it  is  finally  sealed  in  jars.  It  is  excellent  for 
flavoring  rice  and  other  insipid  farinaceous  foods  for  convalescents 
and  children. 

Vanilla  is  derived  from  vanilla  beans,  grown  in  Mexico,  Java,  and 
other  tropical  regions.  It  makes  an  agreeable  flavoring  extract  for 
foods  for  invalids  and  children,  such  as  farinaceous  gruels,  custards, 
blancmange,  or  ice  cream,  for,  unlike  the  spices,  it  is  very  bland.  Its 
chief  use  is  in  the  manufacture  of  chocolate  (p.  260). 

Vinegars  are  made  from  wine,  beer,  cider,  various  fruits,  and  even 
from  the  dry  distillation  of  wood.  They  contain,  besides  acetic  acid, 
traces  of  dextrin,  sugar,  organic  acids,  pigment,  extractives,  and  acetic 
ether.  White  vinegar  is  the  best  in  taste  and  odor. 

The  acetic  acid  in  good  French  vinegar  exists  in  the  proportion  of 
5  per  cent.  Ordinary  table  vinegar  contains  between  2  and  7  per  cent. 
The  acidity  enables  this  condiment  to  soften  muscle  fiber  so  that  the 
digestion  is  facilitated  of  tough  meat,  such  as  corned  beef,  boiled 
beef,  and  other  foods  with  firm  structure,  like  salmon,  lobsters,  or 
hard-boiled  eggs. 

Mild  acids,  such  as  vinegar,  favor  digestion  of  tough  cellulose,  and 


CONDIMENTS  AND   SPICES  293 

aid  the  formation  of  sugar.  For  this  reason  vinegar  is  a  wholesome 
addition  to  coarse,  fibrous,  or  stringy  vegetables,  such  as  beets,  cab- 
bage, and  spinach,  and  to  raw  vegetables,  such  as  cucumbers,  celery, 
cole,  lettuce,  and  like  materials  used  in  salads.  If  vinegar  taken  in 
a  salad  dressing  disagrees,  white  wine  may  be  substituted  with  pepper 
or  mustard  and  oil.  Vinegar  often  is  eaten  with  baked  beans,  but 
it  is  said  to  make  their  legumin  less  soluble. 

Vinegar  has  a,  well-known  antiseptic  and  preservative  action,  and 
hence  its  use  for  pickling  fish,  oysters,  fruits,  and  vegetables. 

Pickles  are  indigestible,  and  should  take  no  part  in  an  invalid 
dietary.  An  excess  of  vinegar  habitually  consumed  with  pickles,  or 
otherwise,  causes  anemia  and  emaciation  by  lessening  the  number  of 
red  corpuscles  and  reducing  the  alkalinity  of  the  blood. 

Vinegar  is  often  adulterated,  and  this  is  especially  true  of  that  used 
for  the  cheaper  varieties  of  pickles,  and  weak  sulphuric  acid  is  quite 
often  employed  for  this  purpose. 

Spurious  vinegar  is  made  by  passing  alcohol  over  beechwood  shav- 
ings which  supply  bacteria  that  develop  acetic  acid  by  oxidation  of  the 
alcohol,  which  is  then  diluted  and  colored  to  appear  like  vinegar. 

Sauces,  such  as  Worcestershire,  Tabasco,  tomato  catsup,  etc.,  are 
used  to  stimulate  a  flagging  appetite,  and  add  flavor  to  soups,  broths, 
etc.  Taken  in  moderation,  they  are  not  injurious,  and  in  cases  of 
alcoholism  sometimes  are  useful  by  inducing  the  patient  to  take 
more  food  and  less  liquor. 

For  invalids,  for  whom  strong  sauces  of  this  kind  always  should 
be  forbidden,  a  very  good  substitute  may  be  made  for  use  with  broiled 
fish,  etc.,  as  suggested  by  Chambers,  by  boiling  a  few  plain  aromatic 
herbs,  like  parsley  or  mint,  in  a  little  water,  and  adding  pepper  and 
salt. 

Horse-radish  is  a  condiment  which  excites  the  flow  of  saliva  and 
gastric  juice  when  eaten  early  in  the  course  of  a  meal  with  meat  or 
raw  oysters,  or  otherwise. 

Flavoring  substances  are  numerous,  such  as  paprika,  capers,  cara- 
way seeds,  aniseed,  saffron,  wintergreen,  bay,  paprika,  liquorice, 
mint,  peppermint  and  various  essential  oils.  Their  use  is  purely  to 
furnish  variety  and  stimulate  the  appetite,  and  they  have  no  nutrient 
value. 


PART  III 

COOKING 

FOOD  PEEPAEATION  AND  PEESEEVATION 
THE  QUANTITY  OF  FOOD  EEQUIEED 

COOKING 

The  Object  of  Cooking  Food. — Although  man  is  so  constituted  that 
it  is  possible  for  him  to  live  upon  raw  food  there  are  no  savage  races 
known  who  do  not  practice  the  art  of  cooking,  in  however  elementary 
a  fashion,  and  progress  in  the  scale  of  civilization  is  uniformly  ac- 
companied by  advance  in  this  art.  Prehistoric  man  may  have  lived 
wholly  on  raw  food,  berries,  fruits,  shellfish,  etc.,  but  this  diet  is  not 
suited  for  most  tribes  of  man  to-day,  although  the  northern  Eskimo 
still  prefers  his  meat  raw  and  frozen.  It  is  owing  to  the  practice  of 
cookery  that  the  dietary  of  civilized  man  has  been  so  much  enlarged, 
and  it  is  far  less  difficult  to  modify  the  mechanical  preparation  of 
foods  than  the  secretions  which  digest  them. 

Of  the  different  varieties  of  food,  that  which  is  derived  from  ani- 
mals as  a  rule  requires  cooking  more  than  vegetable  food.  It  is  well 
known  that  some  vegetables  and  most  fruits  are  eaten  raw  by  prefer- 
ence without  palling  upon  the  appetite,  but  raw  meat  of  almost  any 
kind  soon  becomes  obnoxious  to  civilized  man.  Eaw  milk,  eggs,  and 
bivalves  are  an  exception  to  this  statement  as  regards  animal  foods. 
The  process  of  cooking  food  accomplishes  in  general  the  following 
purposes : 

I.  Cooking  develops  certain  flavors  in  the  food,  in  meat  particu- 
larly, which  are  agreeable  to  the  palate,  and  thereby  enables  man  to 
secure  variety  in  taste,  which  is  so'  important  a  stimulus  to  the  ap- 
petite. 

IT.  Most  food  is  altered  in  consistence  and  made  softer  by  cook- 
ing, although  this  is  not  always  the  case  (eggs,  for  example,  become 
harder  when  boiled).  The  food  is  therefore  easier  masticated  and 
mixed  with  the  various  digestive  fluids.  The  solidity  of  food  does 
not  necessarily  imply  greater  toughness  —  in  fact,  the  albuminous 
ingredients  of  meat  are  coagulated  and  made  actually  more  solid  by 

294 


COOKING  295 

cooking,  but  at  the  same  time  become  less  tough  or  more  friable,  in 
which  condition  they  are  more  easily  ground,  torn,  and  separated  by 
the  teeth. 

III.  The  chemical  changes  produced  in  food  by  cooking  in  some 
instances  favor  the  action  of  the  digestive  juices.     This  is  particu- 
larly true  of  starch  and  of  many  meats. 

Analyses  of  food  are  usually  conducted  upon  the  raw  materials, 
and  the  important  alterations  which  are  occasioned  by  heat  in  vari- 
ous degrees  are  imperfectly  understood  by  most  persons. 

IV.  By  cooking,  many  varieties  of  parasites  and  germs  which  may 
be  contained  in  the  food  are  destroyed,  and  spoiled  food  which  other- 
wise might  be  poisonous  or  injurious  owing  to  their  presence  may  be- 
come harmless. 

V.  The  temperature  of  food  which  is  sometimes  eaten  hot  may 
in  some  cases  favor  the  digestive  processes,  although  the  importance 
of  this  consideration  may  be  exaggerated. 

VI.  The  appearance  of  the  food  is  improved,  and  it  becomes  more 
appetizing  on  this  account. 

Varieties  of  Cooking. —  The  several  processes  of  cooking  in  common 
use  are  as  follows :  1.  Boiling.  2.  Stewing.  3.  Boasting.  4.  Grill- 
ing, or  broiling.  5.  Frying.  6.  Braising.  7.  Baking.  8.  Steaming. 

There  is  undoubted  advantage  in  varying  the  different  methods 
of  cooking  as  well  as  of  flavoring  the  food  from  time  to  time.  Mo- 
notony of  diet  and  of  flavors  lessens  the  appetite  and  fails  to  stimu- 
late the  digestive  organs.  When  variety  in  foods  cannot  be  obtained, 
variety  in  cookery  may  be  made  to  replace  its  advantages.  Every  one 
is  familiar  with  the  effect  on  the  appetite  of  an  occasional  change  of 
cooks  or  of  a  meal  served  amid  unwonted  surroundings. 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
cooking  for  the  sick.  Miss  Xightingale  wrote  that  "  a  good  sick- 
cook  will  save  the  digestion  half  its  work/'  and  invalid  cookery  should 
form  the  basis  of  every  trained  nurse's  education.  It  is  impossible 
herein  to  do  more  than  explain  the  theory  of  the  chief  methods  of 
cooking  and  suggest  their  influence  upon  digestion. 

As  a  rule,  twice-cooked  meats  are  undesirable  for  invalids.  They 
are  apt  to  be  drier  and  less  nutritious  and  digestible  than  when  fresh. 
In  meat  "hash,"  for  example,  the  meat  fiber  is  too  much  hardened. 
Such  preparations  are  often  made  too  greasy  by  recooking  for  delicate 
stomachs.  The  same  statement  applies  to  canned  meats  when  warmed 
over,  for  they  have  been  already  cooked  once  in  the  tin. 

It  is  undesirable  to  combine  foods  which  require  different  periods 
for  their  thorough  cooking.  For  example,  soup  needs  less  boiling 


296  FOOD   PREPARATION   AND  PRESERVATION 

than  the  vegetables  added  to  it,  and  they  should  be  partially  cooked 
alone  beforehand,  or  they  will  be  underdone. 

The  necessary  heat  for  cooking  is  obtainable  in  many  ways  —  from 
coal,  wood,  gas,  oil,  steam,  and  electricity  —  and  these  different  meth- 
ods each  possess  advantages  for  particular  foods. 

Cooking,  as  a  rule,  at  a  prolonged  low  temperature  is  more  eco- 
nomical in  its  results  upon  food  than  a  much  shorter  application  of 
high  heat,  and  this  is  the  theory  of  the  famous  "  Count  Eumford 
kitchen." 

1.  Boiling. —  In  some  excellent  remarks  by  Williams  on  the  subject 
of  so-called  boiled  food,  he  points  out  that  the  expression  "  boiled  " 
beef,  or  eggs,  or  potatoes,  implying  that  the  food  has  been  boiled  in 
the  same  manner  in  which  the  water  is  boiled,  i.  e.,  raised  to  212°  F., 
is  an  absurdity.  The  food  is  merely  heated  by  immersion  in  boiling 
water,  and  even  such  water  as  is  contained  in  the  meat  or  potato  is 
not  itself  boiled  in  the  process,  for,  he  says,  "its  boiling  point  is 
higher  than  that  of  the  surrounding  water,  owing  to  the  salts  it 
holds  in  solution.  Thus,  as  a  matter  of  chemical  form  the  boiled 
leg  of  mutton  is  one  that  has  been  cooked  but  not  boiled,  while  the 
roasted  leg  of  mutton  is  one  that  has  been  partially  boiled.  Much 
of  the  constituent  water  of  flesh  is  boiled  out  and  fairly  driven 
away  as  vapor  during  roasting  or  baking,  and  the  fat  on  its  surface 
is  also  more  or  less  dissociated  into  its  chemical  elements,  carbon 
and  water,  as  shown  by  the  browning  due  to  the  separated  carbon." 

It  is  a  scientific  fact  which  is  not  appreciated  by  many  persons 
that  when  water  has  once  reached  the  boiling  point,  its  temperature 
cannot  be  further  elevated  until  it  is  all  converted  into  steam,  for  all 
the  additional  heat  which  is  required  above  that  needed  to  warm  the 
water  and  drive  off  the  air-bubbles  in  the  process  of  ebullition  is 
expended  in  vaporizing  the  water.  Consequently,  however  hot  the 
fire,  or  however  prolonged  the  cooking,  the  temperature  of  the 
food  suspended  in  boiling  water  cannot  be  increased  above  that  of 
the  water  itself;  and,  in  fact,  the  temperature  of  the  interior  of 
large  masses  of  food,  like  potatoes  or  meat,  is  only  raised  to  about 
190°  F. 

Food  in  the  process  of  canning  placed  in  the  can  in  a  boiling 
salt  water  bath,  is  raised  to  from  165°  to  208°  F. 

There  is  practically  no  distinction  between  "  simmering  "  and  boil- 
ing as  a  process  of  cooking,  except  that  the  violent  boiling  of  some 
foods  tends  to  soften  them  on  account  of  the  commotion  produced 
in  the  water  by  the  rising  bubbles  which  cause  currents  to  form 
that  carry  particle?  of  suspended  food  with  them  and  triturate  them. 


COOKING  297 

The  operation  of  boiling  if  continued  for  an  hour  or  more  gradu- 
ally converts  the  connective  tissue  of  meat  fiber  into  gelatin,  which 
is  partially  dissolved  in  water,  and  the  heat  of  the  boiling  water 
usually  melts  a  little  of  the  fat,  which,  being  unable  to  mix  with  the 
water,  forms  a  scum  upon  the  surface.  A  small  proportion  of  the 
juices  of  meat  usually  osmoses  out  into  the  surrounding  water,  and 
the  aqueous  solution  thus  formed  is  called  broth  or  bouillon.  The 
richness  of  the  broth  will  depend  principally  upon  the  method  of 
conducting  the  boiling  process.  When  it  is  desired  to  have  the 
broth  as  nutritious  as  possible  the  meat  should  be  finely  minced 
and  put  into  cold  water,  which  is  gradually  warmed  but  not  actually 
brought  to  the  boiling  point.  By  this  process  the  juices  of  the  meat 
are  slightly  dissolved  out  into  the  warm  water,  and  thereafter,  if 
the  temperature  is  not  carried  above  160°  F.,  coagulation  of  the 
albumin  in  the  muscle  fibers  does  not  occur,  and  more  and  more  of 
their  constituents  are  dissolved  out  into  the  surrounding  water  — 
but  this  is  not  true  boiling.  In  this  manner  the  natural  flavor  is 
much  better  preserved ;  in  fact,  the  common  extracts  of  meat  are  made 
by  soaking  finely  chopped  meat  in  cold  water  and  subsequently 
evaporating  the  water  from  the  ingredients  which  are  found  in  it. 

On  the  other  hand,  when  broth  is  not  wanted  for  nutriment  it  is 
desirable  to  prevent  the  solution  of  the  juices  in  the  water  by  im- 
mersing the  meat  suddenly  into  water  actually  boiling,  so  that  the 
outer  layer  of  the  mass  will  be  hardened  by  coagulation  and  have  a 
firm  coating  which  is  not  permeated  by  the  juices  within.  When 
meat  is  cooked  in  this  manner  the  broth  is  scarcely  of  any  food 
value,  but  the  meat  is  much  more  palatable.  After  the  boiling  tem- 
perature of  the  water  has  been  maintained  for  five  minutes  the 
further  cooking  should  be  continued  at  a  lower  temperature  of,  say, 
165°  to  170°  F.  If  the  heat  is  less  than  this,  the  interior  of  the 
joint  or  other  piece  of  meat  is  imperfectly  cooked  and  its  albumin 
is  insufficiently  coagulated,  so  that  it  has  a  raw  appearance.  If  the 
actual  boiling  point  is  long  maintained,  the  albumin  is  too  firmly 
coagulated,  and  the  meat  becomes  tough  and  stringy.  The  latter 
error  in  boiling  is  very  commonly  perpetrated  by  cooks.  The  coagula- 
tion point  of  different  forms  of  albumin  varies,  ranging  from  below 
90°  to  above  165°  F.,  and  since  many  varieties  of  albumin  occur  in 
the  different  kinds  of  animal  food,  it  will  be  found  that  they  are 
not  all  equally  well  cooked  by  exactly  the  same  temperature.  Am- 
monium sulphite  is  liberated  by  continued  boiling,  and  also  an  acid 
resembling  acetic  acid. 

When  meat  is  plunged  into  boiling  water  so  that  the  external 
22 


298  FOOD   PREPARATION   AND   PRESERVATION 

layers  are  solidified,  some  of  the  water  which  they  contain,  with  5  to 
8  per  cent  of  soluble  substances,  is  squeezed  out  into  the  surrounding 
fluid,  and  an  actual  loss  of  weight  in  the  meat  occurs  which  may 
reach  as  high  as  30  per  cent. 

The  addition  of  salt  to  water  in  boiling  fish  or  meat  is  described 
by  Williams  as  having  a  threefold  action:  (1)  It  directly  acts  on 
superficial  albumin  with  coagulating  effect;  (2)  it  slightly  raises  the 
boiling  point  of  the  water;  (3)  by  increasing  the  density  of  the  water, 
the  exosmosis  or  oozing  out  of  the  juices  is  less  active,  and  hence  the 
flavor  is  better  retained. 

When  very  salt  meat  is  to  be  cooked,  if  steeped  too  long  in  boiling 
water  its  nutritive  properties  are  impaired,  the  muscle  sarcolemma 
becomes  too  hard,  and  the  meat  tasteless  and  tough.  In  such  cases 
it  may  be  well  to  boil  meat  less  completely,  and  finish  the  cooking 
by  some  other  method,  such  as  frying. 

2.  Stewing. —  Stewing  differs  from  boiling  in  the  fact  that  the 
juices  of  the  meat  or  vegetables  are  dissolved  in  the  heated  water. 
The  proper  temperature  for  stewing  is  between  135°  and  160°  F.  In 
thick  stews  the  juices  dissolved  in  the  water  are  eaten  together  with 
the  cooked  food,  but  in  some  instances,  as  in  the  making  of  beef 
tea  and  some  kinds  of  soups,  the  aqueous  solution  only  is  used.  Ob- 
viously, the  more  the  food  is  subdivided  the  greater  the  surface  ex- 
posed to  the  solvent  action  of  the  water,  and  hence  the  object  of 
mincing  meat  thoroughly  which  is  to  be  used  in  the  preparation  of 
beef  tea.  If  such  minced  meat  has  been  soaked  for  a  long  time  in 
cold  water,  a  part  of  the  albumin  and  the  extractive  materials  are 
obtained  in  solution,  but  the  meat  which  is  left  is  colorless,  taste- 
less, and  unpalatable;  in  fact,  animals  fed  upon  it  soon  deteriorate 
in  strength. 

More  or  less  water  enters  the  substance  of  the  meat  to  replace 
the  juices  which  have  passed  out  by  osmosis  and  diffusion  into  the 
surrounding  fluid.  After  meat  has  been  stewed  for  some  time  a 
scum  containing  a  little  coagulated  albumin  and  more  or  less  fat 
is  seen  floating  upon  the  surface.  This  is  usually  removed  in  the 
preparation  of  beef  tea  for  invalids  in  order  to  make  it  more  palatable 
and  agreeable  to  the  eye,  but  its  removal  is  at  the  expense  of  con- 
siderable nutritious  material.  In  the  preparation  of  extracts-  of 
meat,  such  as  Liebig's  Extractum  Carnis,  the  scum  is  removed  be- 
fore the  solution  is  concentrated  by  evaporation. 

Stows  made  in  the  manner  described  above,  and  which  consist 
largely  of  meat  and  plain  sliced  vegetables,  are  fairly  digestible: 
but  if  other  materials  or  rich  sauces  are  added  to  them,  this  is  not 


COOKING  299 

the  case,  and  if  saturated  with  fat,  they  are  quite  unfit  for  invalids. 
As  both  the  solid  substance  of  the  meat  and  vegetables  and  the  fluid 
materials  which  have  been  extracted  from  them  are  eaten  together 
in  the  stew,  this  is  an  economical  form  of  preparing  food. 

3.  Roasting.  4.  Grilling. —  The  processes  of  roasting  and  grilling 
or  broiling,  when  performed  over  a  very  hot  fire,  result  in  cooking 
the  meat  in  a  manner  which  is  in  some  respects  analogous  to  stew- 
ing; in  fact,  the  interior  portions  of  the  meat  are  stewed  in  their 
own  juices  instead  of  in  water  as  in  boiling  (Williams).  A  coating 
of  coagulated  albumin  forms  upon  the  outer  surface  of  the  meat, 
while  the  albuminous  material  or  myosin  of  the  interior  is  gradually 
warmed  and  slowly  coagulated.  The  outer  coating  prevents  the 
evaporation  of  the  juices  of  the  meat  which,  together  with  the  ex- 
tractive materials,  are  retained,  and  add  flavor  to  it.  Eoasted  and 
broiled  meats  therefore  have  a  decided  advantage  in  flavor  as  well 
as  in  nutritive  value  over  meat  which  has  been  boiled  for  a  long 
time,  although  the  latter  may  be  tender  and  easily  digested. 

Roasting  and  broiling  are  the  most  universal  methods  of  cook- 
ing. For  them  the  savage  or  the  hunter  requires  no  utensils,  but 
boiling  implies  the  aid  of  the  potter  or  worker  in  metals.  The 
Polynesian  cooks  his  meat  by  roasting  it  on  a  hot  stone,  and  sprinkles 
it  with  sea  water  to  obtain  the  salt.  The  primitive  hunter  incases 
his  meat  or  wild  fowl,  skin  and  all,  in  damp  clay  and  roasts  it  in  hot 
coals.  The  Australian  savage,  the  lowest  type  of  man,  does  all  his 
cooking  by  roasting. 

In  roasting  as  in  boiling,  the  heat  should  be  strong  when  first 
applied,  but  it  subsequently  should  be  reduced  to  prevent  charring 
of  the  surface.  This  may  be  accomplished  by  removing  the  meat 
farther  away  from  the  fire.  The  main  object  of  an  oven  is  to  pre- 
vent burning  by  uneven  cooking. 

The  principle  of  a  roasting  oven  is  formulated  by  Williams,  who 
says  "the  meat  should  be  cooked  by  the  action  of  radiant  heat  pro- 
jected towards  it  from  all  sides  while  it  is  immersed  in  an  atmos- 
phere nearly  saturated  with  its  own  vapor/'  and  the  heat  applied 
after  reaching  a  maximum  is  kept  uniform  throughout  the  process. 

In  boiling  or  stewing,  the  heat  is  applied  to  the  meat  by  convec- 
tion through  water,  and  this  is  an  important  discrimination  because 
the  air  which  surrounds  the  roasting  meat  is  constantly  removing 
the  water  which  tends  to  evaporate  upon  its  surface,  and  therefore 
to  dry  the  external  surface  of  the  meat,  From  20  to  34  per  cent  of 
water  is  lost  in  this  manner,  and  the  meat  therefore  weighs  less. 
The  evaporation  of  this  water,  which  continually  passes  from  the 


300  FOOD   PREPARATION   AND  PRESERVATION 

interior  of  the  meat  towards  the  outer  surface,  produces  a  loss  of 
heat  in  the  meat  itself  which  keeps  the  interior  from  bcoming  over- 
heated. If  the  roasting  or  broiling  be  long  continued,  the  water 
gradually  passes  out  more  and  more  from  the  interior  of  the  mass, 
which  finally  becomes  dry  and  hardened  or  burned.  If  too  much  air 
surrounds  the  meat,  it  is  poorly  roasted,  dry,  and  leathery,  whereas 
if  the  heat  be  applied  more  directly  by  radiation  from  glowing  embers, 
the  sudden  hardening  of  the  outer  coating  of  the  meat,  even  though 
it  be  slightly  burned,  forms  a  barrier  against  the  evaporation  of 
water  from  the  interior. 

Broiling  or  grilling  is  a  means  of  quick  cooking  which  requires 
very  much  less  time  than  roasting  or  boiling,  because  intense  heat  is 
applied  to  comparatively  small  pieces  of  meat  or  fish.  It  is  really 
roasting  on  a  smaller  scale. 

The  object  of  broiling  as  well  as  of  quick  roasting  should  be  to 
raise  the  interior  of  the  mass  promptly  to  the  point  of  coagulation, 
or  about  180°  F.,  so  that  the  water  within  shall  not  have  time  to 
evaporate  wholly.  It  is  for  this  reason  that  steaks  and  chops  are 
often  best  cooked  in  restaurants,  where  specially  adapted  grills  are  used 
which  bring  the  meat  in  closer  relation  to  a  radiant  surface  of  glow- 
ing coals  than  is  usually  possible  in  domestic  cookery.  A  properly 
cooked  steak  or  chop  is  thickened  in  the  center.  It  should  be  re- 
membered that  the  evaporation  depends  upon  the  extent  of  the 
surface  of  the  meat,  and  for  this  reason  thinly  cut  steaks  or  chops 
become  comparatively  dry  and  shriveled  in  the  center.  This  prin- 
ciple is  well  described  by  Williams,  who  says  that  "the  smaller  the 
joint  to  be  roasted,  the  higher  the  temperature  to  which  its  surface 
should  be  exposed,"  and  when  very  large  masses  of  meat  are  being 
cooked,  it  becomes  necessary  to  secure  time  for  the  heat  to  penetrate 
into  the  interior  without  drying  up  the  outside.  This  object  is  ac- 
complished by  constantly  basting  the  surface  in  order  to  keep  it 
wet  and  prevent  evaporation,  for  while  the  surface  is  moistened,  its 
temperature  will  not  rise  above  the  boiling  point  of  the  liquid  which 
is  used  to  moisfen  it.  Pouring  melted  fat  or  melted  butter  over  the 
meat  checks  evaporation  almost  completely. 

The  roasting  of  any  meat,  however,  cannot  be  accomplished  with- 
out the  effusion  of  some  of  the  meat  juice  and  the  melting  of  a 
portion  of  the  superficial  fat  and  of  gelatin.  These  substances  to- 
gether constitute  the  meat  gravy,  which  is  itself  quite  nutritious. 
In  overroasted  or  "  burned  "  meat  the  external  layers  become  scorched 
or  charred,  and  this  is  due  chiefly  to  the  carbonizing  of  the  fat. 
Before  the  fat  has  become  fully  burned,  certain  volatile  fatty  acids 


COOKING  301 

are  liberated  which  have  a  very  disagreeable  odor,  and  various  prod- 
ucts are  developed  which  are  not  only  of  no  value  for  nutrition,  but 
which  may  be  positively  irritating  to  the  alimentary  canal.  A  little 
lactic  acid  and  glycerin  are  formed.  According  to  Yeo,  for  beef, 
mutton,  and  game,  a  temperature  of  130°  F.  is  sufficient  for  proper 
cooking  and  the  meat  is  "  rare "  or  "  underdone/'  retaining  much 
of  its  reddish  color;  but  veal  and  poultry  should  be  cooked  at  a 
higher  temperature  —  at  from  158°  to  160°  F.  These  temperatures 
are  lower  than  those  often  used,  which  range  from  300°  to  480°  F., 
and  apply  rather  to  the  degree  which  is  to  be  maintained  after  the 
meat  is  first  placed  in  position  for  roasting,  when  as  previously  stated, 
the  temperature  should  be  much  higher. 

A  rough  rule  is  to  roast  meat  15  minutes  for  each  inch  of  thickness 
of  the  cut,  and  add  15  minutes  "for  the  oven;"  or  13  minutes  per 
pound  produces  "  rare  "  meat  and  20  minutes  "  overdone."  Basting 
lowers  the  temperature  slightly  and  produces  a  rarer  meat. 

Game  or  meat  which  is  "  high  "  or  somewhat  tainted  is  extremely 
repulsive  if  cooked  by  boiling  or  stewing,  when  it  disintegrates  more 
or  less  and  the  elements  of  decomposition  pass  into  and  flavor  the 
whole  mass.  Such  meat,  however,  is  sometimes  palatable,  and  is 
not  necessarily  unwholesome  if  cooked  by  roasting,  when  the  ex- 
ternal layers  which  have  first  commenced  to  decompose  are  thoroughly 
browned  and  thereby  disinfected.  Some  persons  prefer  that  a  leg 
of  mutton  should  be  hung  until  it  becomes  slightly  odorous  before 
it  is  roasted,  but  it  should  be  fresh  for  boiling. 

5.  Frying. —  Frying  is  a  process  of  cooking  by  which  the  heat  is 
transmitted  by  the  contact  of  the  food  with  melted  fat,  butter,  or  oil, 
and  not  by  radiation,  as  in  the  case  of  broiling  or  roasting.  As  ex- 
plained by  Williams,  the  fat  does  not  necessarily  boil,  for  the  food, 
as  well  as  the  fatty  material  itself,  may  contain  a  considerable  pro- 
portion of  water  which,  by  being  suddenly  vaporized,  produces  the 
familiar  spluttering  which  accompanies  the  process  of  frying. 

The  boiling  point  of  fats  is  very  much  above  that  of  water,  but 
fats  and  oils  used  in  cooking  when  heated  above  400°  F.  turn  dark 
brown  or  black  and  emit  a  disagreeable  odor  and  smoke,  leaving  a 
nonvolatile  carbon  residue. 

In  frying,  the  heat  is  suddenly  applied,  and  as  a  result  the  ex- 
ternal surface  of  the  food  mass  is  coagulated  and  hardened  before 
the  juices  in  the  interior  have  time  to  escape.  For  this  reason,  deli- 
cate fish,  like  the  trout,  is  more  highly  flavored  and  palatable  when 
fried  than  boiled.  More  or  less  butyric  acid  is  developed  from  fat 
in  frying. 


302  FOOD  PREPARATION   AND  PRESERVATION 

The  popular  idea  in  regard  to  frying  is  that  the  fat  used,  whether 
butter,  lard,  or  drippings,  is  simply  for  the  purpose  of  preventing 
food  from  adhering  to  the  frying  pan,  but,  from  the  explanation  of 
the  process  quoted  above,  it  is  seen  that  this  is  not  the  case,  and  the 
best  frying  is  done  by  immersing  the  food  completely  in  a  bath  of 
fat  or  oil.  Even  olive  or  sperm  oil  may  be  used  for  this  purpose, 
and  the  fish  or  other  food  is  lowered  in  an  open  wire  basket  or  net- 
ting into  a  deep  pan  which  contains  the  fat,  in  which  it  is  completely 
submerged.  There  is  no  danger  of  the  fat  soaking  into  the  food  if 
it  is  sufficiently  hot  and  if  the  process  be  not  too  long  continued,  for, 
as  stated  by  Williams,  "  the  water  amid  the  fibers  of  the  fish  is  boil- 
ing and  driving  out  steam  so  rapidly  that  no  fat  can  enter  if  the 
heat  is  well  maintained  to  the  last  moment."  Fritters  cooked  in 
this  way  are  light  and  puffy  from  the  sudden  expansion  of  the  water 
which  they  contain  into  large  bubbles  of  steam,  and  are  consequently 
decidedly  more  digestible.  Bacon  fries  in  its  own  fat. 

Frying  is  less  perfectly  understood  by  cooks  than  almost  any 
other  method  of  preparing  meat,  and  the  process  as  usually  carried 
out  results  in  very  unwholesome  products.  The  pans  used  are  too 
shallow,  and  both  food  and  fat  are  apt  to  become  scorched. 

When  the  meat  or  other  material  is  dipped  into  hot  melted  oil  or 
fat,  more  or  less  of  it  clings  to  the  surface  of  the  food,  and  for  this 
reason  may  render  it  unfit  for  persons  with  feeble  digestive  powers. 
In  the  case  of  fish  cooked  in  this  manner  with  their  scales,  the  fat 
which  adheres  to  them  may  be  removed  easily  when  eaten,  and  the 
meat  within  will  be  found  to  be  quite  digestible;  but  meat,  such  as 
steak,  cooked  by  frying  is  notoriously  indigestible.  Salt  meat  may 
be  cooked  first  by  boiling  before  frying,  as  in  the  case  of  hams, 
although  the  latter  may  be  roasted  subsequently  instead  of  fried. 
Such  meats  always  require  prolonged  cooking.  According  to  Yeo, 
the  addition  of  a  little  vinegar  tends  to  make  them  more  tender. 

6.  Braising. —  Braising  is  a  method  of  cooking  meat  by  which  it 
is  immersed  in  a  solution  of  vegetable  and  animal  juices  called 
"  braise,"  contained  in  a  covered  vessel,  in  which  it  is  exposed  to  a 
high  but  not  boiling  temperature.  It  is  of  value  especially  for 
cooking  tough  meat  of  any  sort  or  meat  which  is  too  fresh  or  young. 
The  cover  of  the  kettle  is  so  arranged  as  to  prevent  evaporation; 
the  meat  becomes  permeated  in  the  long  cooking  with  the  juices  of 
fresh  vegetables  and  herbs,  and  is  kept  from  drying. 

Towards  the  end  of  the  process  cooking-sherry  or  spices  may  be 
added,  such  as  cloves  or  mace,  or  thin  slices  of  bacon.  The  amount 
of  fluid  used  should  be  barely  sufficient  to  cover  the  meat,  and  in 


COOKING  303 

this  way  the  surrounding  broth  is  kept  very  concentrated.     Some- 
times the  meat  which  is  braised  is  partially  roasted. 

7.  Baking. —  Baked  meat  is   prepared   by  cooking  in  a  confined 
space,  which  prevents  the  volatile  products  which  are  driven  off  in 
roasting  from  escaping,  and  consequently  the  meat  has  a  somewhat 
stronger  and  less  delicate  flavor  than  when  roasted;  it  is  also  richer, 
and  disagrees  with  dyspeptics.     It  becomes  saturated  with  empyreu- 
matic  oils  unless  its  surface  is  protected  by  a  pie  crust,  but  that  does 
not  add  to  its  digestibility. 

The  baking  of  bread  is  described  on  page  164. 

8.  Steaming. —  Cooking  by  steaming  is  a  method  little  used,  ex- 
cept in  hospitals  or  other  institutions  where  large  quantities  of  food 
are  prepared   simultaneously;   it  is  mainly  applied  to  cereals  and 
puddings,  but  also  to  meats,  etc. 

Soups. —  Meat  soups  and  broths  are  made  by  continued  boiling, 
which  converts  the  connective  tissue  of  meat  fibers  into  gelatin,  which 
is  gradually  dissolved  into  the  water.  The  soup  thus  becomes  an 
aqueous  solution  of  gelatin,  with  some  of  the  extracts  of  the  meat  for 
flavoring.  Whatever  albumin  is  dissolved  and  what  little  fat  may 
be  melted  forms  a  scum  on  the  surface.  The  insoluble  albumin 
becomes  coagulated  and  floats  about  in  small  particles,  which  are 
strained  away  if  the  soup  is  to  be  clear,  but  this  process  makes  it 
less  nutritious  for  invalids.  If  a  really  rich  soup  or  nutritious  broth 
is  to  be  made  from  any  piece  of  meat,  so  much  of  the  latter  is  dis- 
solved into  the  water  that  the  residue  is  tasteless,  tough,  and  so 
indigestible  that  it  is  practically  useless.  On  the  other  hand,  there 
are  many  scraps  of  meat  or  parts  which  are  unsightly  or  less  useful 
for  food  from  which  very  nutritious  soups  may  be  made,  and  the 
inedible  bones  are  utilized  in  the  same  manner. 

The  extent  to  which  soups  and  broths  may  be  made  nutritious 
depends  largely  upon  the  character  of  the  meat  used,  and  Parkes 
placed  meats  in  the  following  order  in  regard  to  the  nutritive  value 
of  their  broths,  commencing  with  the  strongest:  Chicken,  mutton, 
and  beef.  He  stated  that  the  best  broth  made  from  beef  contains  150 
grains  of  proteid  to  the  pint  and  90  grains  of  salts,  for  nearly  all 
of  the  salts  of  the  beef,  chiefly  chlorides  and  phosphates,  dissolve 
out  into  the  surrounding  water.  Beef  tea  is  described  on  page  136. 

Experiments  on  losses  in  cooking  meat,  conducted  in  1903  by 
H.  S.  Grindley  and  Timothy  Mojonnier,  at  the  University  of  Illinois, 
led  to  the  following  very  practical  conclusions: 

"  1.  "When  beef  was  cooked  in  water  in  these  experiments,  3.25 
to  12.67  per  cent  of  the  nitrogenous  matter,  0.60  to  37.40  per  cent 


304  FOOD  PREPARATION   AND  PRESERVATION 

of  the  fat,  and  20.04  to  67.39  per  cent  of  the  mineral  matter  of  the 
original  uncooked  meat  were  found  in  the  broth.  The  nutritive  ma- 
terial thus  removed  has  been  designated  as  a  loss,  but  it  is  not  an 
actual  loss  if  the  broth  is  utilized  for  soup  or  in  other  ways. 

"  2.  When  meat  is  sauteed  2.15  per  cent  of  the  nitrogenous  mat- 
ter and  3.07  per  cent  of  the  ash  occurring  in  the  uncooked  meat  were 
taken  up  on  an  average  by  the  fat  in  which  the  meat  was  cooked, 
while  the  cooked  meat  contained  2.3  times  more  fat  than  before 
cooking. 

"  3.  When  the  meats  were  roasted,  0.25  to  4.55  per  cent  of  the 
nitrogenous  matter,  4.53  to  57.49  per  cent  of  the  fat,  and  2.47  to 
27.18  per  cent  of  the  mineral  matter  present  in  the  uncooked  meat 
were  found  in  the  drippings. 

"  4.  Beef  which  has  been  used  for  the  preparation  of  beef  tea 
or  broth  has  lost  comparatively  little  in  nutritive  value,  though 
much  of  the  flavoring  material  has  been  removed. 

Cooking  of  Fish. —  Fish  may  be  cooked  by  boiling,  grilling,  baking, 
frying,  or  stewing.  Of  these  several  methods,  boiling  is  decidedly 
the  most  advantageous  for  persons  with  feeble  digestions,  and  next 
in  order  is  broiling.  When  fish  is  boiled  without  the  addition  of 
salt  to  the  water  it  becomes  soft  and  disintegrated,  but  if  boiled 
in  sea  water  or  artificially  salted  water  it  maintains  its  shape  and 
flavor,  for  the  salt  regulates  the  osmosis  of  the  juices  of  the  fish  into 
the  water.  As  a  rule,  fish  requires  much  less  time  than  meat  for 
cooking. 

If  fried  fish  is  to  be  eaten  by  dyspeptics,  it  should  be  cooked  whole, 
and  the  skin  carefully  removed  subsequently.  It  is  never  as  di- 
gestible as  boiled  fish. 

Cooking  of  Vegetables. —  The  object  of  cooking  vegetables,  as  in 
the  case  of  cooking  meat,  is  to  render  them  more  digestible,  to  give 
variety,  to  modify  their  flavor,  and  in  some  cases  to  preserve  them. 

Some  coarse  vegetables,  such  as  turnips,  carrots,  beets,  and  pota- 
toes, while  they  make  good  raw  food  for  animals,  are  unpalatable 
and  indigestible  for  man,  and  require  softening  and  alteration  by 
prolonged  boiling  in  soft  water  or  by  some  other  form  of  cooking. 
The  cooking  of  vegetables  macerates  the  cellular  fibers  or  walls  of 
the  cells  and  softens  their  contents,  rendering  them  more  easy  of 
mastication,  while  the  effect  of  the  heat  and  moisture  is  to  cause 
swelling  and  rupture  of  the  starch  granules,  in  which  condition  they 
are  more  easily  and  promptly  acted  upon  by  the  starch-digesting 
ferments  contained  in  the  saliva  and  pancreatic  juice. 

Most  vegetables  contain  a  very  large  percentage  of  water  in  their 


FOOD  CONCENTRATION  —  CONDENSED  FOOD  305 

natural  state,  but  in  many  of  the  cooking  processes  to  which  they 
are  subjected,  excepting  perhaps  in  baking  potatoes  and  the  like, 
water  is  added  in  considerable  quantity,  either  hot  or  cold. 

FOOD  CONCENTRATION  — CONDENSED  FOOD 

The  concentration  of  food  is  based  upon  the  fact  that  many  foods 
contain  a  large  percentage  of  free  water,  which  can  be  driven  off  by 
evaporation,  thereby  reducing  the  weight,  and  usually  the  bulk  of 
the  food  as  well.  Slight  further  condensation  may  be  accomplished 
by  hydraulic  pressure. 

Drying.  Desiccation.  Extracts. —  If  the  process  of  drying  is  not 
carried  beyond  a  partial  evaporation,  the  food  is  called  "  condensed." 
It  may,  however,  be  continued  until  the  food  is  completely  dry,  in 
which  case  the  substance  may  be  either  "  desiccated  " —  i.  e.,  torn  into 
shreds  —  or  pulverized.  Condensed  and  powdered  foods  may  be 
added  to  other  foods  in  order  to  thicken  them  or  increase  their 
nutritive  power. 

The  nutritive  principles  of  foods  may  be  extracted  by  glycerin 
or  acid  solutions  and  other  materials,  and  the  resulting  extract  is  con- 
densed by  evaporation  to  the  consistence  of  a  paste  or  powder.  Be- 
yond this  it  is  not  possible  to  concentrate  foods  by  chemical  process, 
for  a  definite  bulk  of  food  must  be  daily  consumed  from  which  to 
derive  the  energy  for  the  body  and  the  substances  needed  for  repair. 

Drying  is  conducted  either  in  the  heat  of  the  sun  or  by  artificial 
means.  The  class  of  dried  foods  embraces  the  various  forms  of  dried 
and  desiccated  meat  and  fish,  dried  milk,  dried  vegetables  and  fruits, 
such  as  peas,  beans,  lentils,  corn,  okra,  apples,  peaches,  cocoanuts, 
grapes  (raisins),  dates,  prunes,  figs,  etc.  The  addition  of  sugar, 
flour  or  salt  by  abstracting  moisture,  aids  the  drying  and  helps  to 
prevent  decomposition. 

Milk  may  be  dried  in  vacua  and  preserved  by  itself  as  a  powder, 
or  mingled  with  other  materials,  such  as  malt  and  various  starchy 
foods.  Condensed  milk  is  described  on  p.  108. 

Eggs  may  be  successfully  dried;  they  keep  well,  especially  when 
mixed  with  farinaceous  materials  (p.  124). 

Froissart  relates  how  the  King  of  France  in  the  invasion  of  Eng- 
land in  1386  had  the  yolks  of  eggs  packed  and  stored  in  barrels  to 
furnish  rations  for  the  troops.  Egg  albumen  dries  in  the  form  of 
thin  scales  which  may  be  preserved  indefinitely. 

Meat. —  The  preservation  of  meat  and  fish  by  drying  is  probably 
the  most  primitive  method  in  use.  Meat  drying  is  practiced  ex- 


306  FOOD   PREPARATION   AND   PRESERVATION 

tensively  among  savage  tribes  in  almost  all  parts  of  the  world,  but 
especially  where  purity  of  the  atmosphere  combined  with  intense  heat 
and  dryness  of  climate  will  cause  the  water  to  evaporate  from  the  meat 
so  rapidly  that  germs  do  not  have  time  to  decompose  it.  For  this 
purpose  only  lean  meat  can  be  used,  as  the  fat  does  not  part  with 
its  water  with  sufficient  readiness.  "  Jerked  "  meat  is  prepared  by 
cutting  into  thin  slices  and  drying  in  the  sun  for  several  days.  Dried 
meat  loses  much  in  weight,  becomes  hard  and  tough,  and  in  many 
cases  tasteless.  It  is  therefore  usually  indigestible,  and  requires  pro- 
longed cooking  and  proper  seasoning.  Dried  meat  may  be  predi- 
gested,  evaporated,  powdered,  and  made  into  a  paste  for  broths,  or 
used  to  reinforce  various  food  preparations  for  invalids.  Powdered 
meat  is  sometimes  mixed  with  sugar  and  salt,  or  pulverized  dried 
cooked  vegetables,  bread,  etc.  Dried  meat  extracts  have  been  de- 
scribed in  detail  on  pp.  132  to  135. 

Pemmican  is  a  preparation  of  dried  powdered  meat,  which  has 
been  described  on  p.  233. 

Dried  vegetables  keep  even  better  than  dried  meats.  Tea  and 
coffee  are  good  examples  of  dried  vegetable  substances.  They  may 
be  extracted  and  then  concentrated  by  evaporation.  Potatoes  are 
concentrated  by  drying  to  less  than  one-third  of  their  original  weight, 
and  they  may  be  preserved  thus  in  slices  or  granular  form.  Many 
other  vegetables  are  prepared  by  drying,  and,  in  addition,  some  are 
compressed,  as,  for  example,  cabbage,  cauliflower,  carrots,  etc.  The 
compression  still  further  excludes  air  and  moisture.  As  a  rule,  dried 
vegetables  are  only  serviceable  for  relieving  monotony  of  diet  when 
fresh  vegetables  cannot  be  obtained.  Desiccated  vegetables  have  been 
used  with  some  success  in  the  United  States  navy,  but  they  have 
less  antiscorbutic  property  than  fresh  foods. 

Bread  may  be  preserved  for  a  long  time  by  drying,  but  it  usually 
becomes  tasteless,  and  is  useful  in  this  condition  only  in  emergencies, 
or  to  make  variety  in  the  rations  of  sea  biscuits,  hard-tack,  etc., 
which  are  furnished  to  soldiers  and  sailors  in  active  service. 

Major  "Woodruff,  Surgeon,  U.  S.  A.,  writes  on  this  subject:  "By 
a  new  process,  which  probably  consists  in  drying  the  bread  and  at 
the  same  time  compressing  it  by  improved  machinery,  the  Germans 
have  secured  a  variety  of  field  bread  which  is  spoken  of  in  very  high 
terms.  Small  bits  of  it  thrown  into  soup  swell  up  like  a  dried 
sponge  when  thrown  into  hot  water.  The  soldiers  are  said  to  be 
very  fond  of  it,  and  as  far  as  known  it  is  entirely  successful.  .  .  . 

"  The  French  Department  of  Intendance  has  been  experimenting 
with  dried  bread,  which  is  said  to  be  superior  for  campaigning  pur- 


FOOD   CONCENTRATION  —  CONDENSED   FOOD  307 

poses  both  to  biscuit  and  ordinary  bread.  From  the  results  of  the 
experiment,  which  are  given  in  the  Eevue  du  Service  de  1'Intendance 
Militaire,  it  appears  that  this  dried  bread  will  absorb  from  five  to  six 
times  its  own  weight  of  water,  milk,  tea,  coffee,  or  bouillon.  Biscuit 
absorbs  hardly  its  own  weight  of  liquid,  although  when  thoroughly 
dried  it  contains  only  about  10  per  cent  of  water,  whereas  the  bread 
contains  from  12  to  14  per  cent.  It  can  be  made  in  cubes  of  con- 
venient form." 

Diet  of  Concentrated  Foods 

There  are  many  complex  dried  foods  in  market  prepared  espe- 
cially for  invalid  diet,  and  supposed  to  possess  high  nutritive  value 
with  small  bulk.  As  compared  with  fresh  food,  their  lighter  weight 
and  greater  concentration  make  them  valuable  articles  for  temporary 
invalid  diet,  but  they  cannot  be  said  to  possess  any  special  advan- 
tage over  freshly-made  broths,  scraped  beef,  etc.,  excepting  in  those 
cases  in  which  it  is  important  to  lessen  the  bulk  and  increase  the 
strength  of  the  food. 

Attempts  have  from  time  to  time  been  made  in  the  German  army 
and  elsewhere  to  supply  healthy  men  with  a  daily  diet  of  concen- 
trated foods.  If  this  could  be  done,  it  would  be  of  great  economic 
advantage  for  troops  on  the  march,  explorers  in  unknown  countries, 
sailors  on  long  voyages,  and  for  use  in  many  ways,  but  after  a  few 
days  or  a  week  of  such  treatment  men  lose  in  weight  and  deteriorate 
in  strength.  It  is  not  found  practical  to  give  food  for  any  length 
of  time  in  which  the  total  solid  ingredients  are  concentrated  to  less 
than  twenty-two  or  twenty-three  ounces  for  the  day's  ration,  although 
for  a  few  days  food  may  be  used  in  which  they  have  been  reduced 
to  ten  or  twelve  ounces.  Pea  meal  (p.  193)  and  pemmican  (p.  233) 
are  the  most  noted  rations  of  this  class,  to  which  bacon,  hard-tack, 
concentrated  meat  extracts,  coffee,  and  chocolate  are  often  added. 

In  a  series  of  very  instructive  and  important  articles  upon  Military 
Food,  published  in  the  Journal  of  the  American  Cavalry  Associa- 
tion, Major  Woodruff  says :  "  Concentration  only  means  the  exclusion 
of  the  indigestible  portions  and  part  of  the  water.  Thus  the  gar- 
rison ration  gives  to  each  man  about  five  pounds  of  food,  of  which 
only  four  pounds  are  eaten,  and  it  is  impossible  to  condense  this 
amount  so  that  it  will  be  much  less  than  three  pounds.  All  foods 
that  are  compressed  and  dried  still  contain  from  5  to  12  per  cent  of 
water.  The  German  soldier's  war  ration  is  equivalent  to  about  two 
pounds  of  water-free  food  in  the  above  sense.  This  is  not  enough 
for  American  soldiers  during  hard  work,  yet  it  is  possible  in  an 


308 


FOOD  PREPARATION   AND  PRESERVATION 


emergency  to  give  the  soldier  fairly  good  nourishment  with  these 
improved  foods,  and  not  allow  the  weight  to  be  over  two  pounds, 
as  seen  in  the  following  table,  in  which  the  analyses  are  only  ap- 
proximate : 


ARTICLES. 

GRAMS. 

Calories. 

Weights 

Protein. 

Fats. 

Carbo- 
hydrates. 

Salts. 

3     cubes    dried    compressed 
bread,  14  pound  each  .... 
3  packages  compressed  soup, 
6  ounces  each  

35 
100 

4 
150 

250 
200 

2 

28 

1,233 
2,625 

1    pound. 
1J        " 

1        " 

3  tablets  compressed  tea  or 
coffee  ready  for  use,  possi- 
bly a  tablet  of  dried  fruit 

Total  

135 

154 

450 

30 

3,858 

*  2  pounds. 

*  Gross  weight. 

"  For  purposes  of  detached  service  the  United  States  soldier  has 
been  supplied  with  a  concentrated  ration  as  seen  in  the  following 
table : 


ARTICLES. 

GRAMS. 

Calories. 

Weights. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Salts. 

1  pound  hard-tack   

50 

27 

5 
236 

340 

HNH« 

(NOD  OS 

1,644 
2,310 

1    pound. 
1 

1         " 

%  pound  bacon  

Coffee,  sugar,  and  salt   .... 

Total   

77     , 

241 

340 

30 

3,954 

2  pounds." 

FOOD  PRESERVATION 

The  different  methods  of  food  preservation  have  of  late  years  re- 
ceived much  attention,  for  it  is  owing  to  them  very  largely  that  it 
is  possible  to  maintain  large  armies  and  navies  in  action  and  to 
permit  of  the  aggregation  of  men  in  communities  away  from  all 
immediate  sources  of  food  supply. 

It  was  originally  believed  that  contact  with  air  was  per  se  the 
cause  of  the  decomposition  of  food,  but  it  is  now  known  that  the 
great  number  of  germs  contained  in  even  comparatively  "  pure " 
atmospheric  air  are  the  agents  of  putrefaction  rather  than  the  air 
itself,  but  the  exclusion  of  the  latter  implies  the  exclusion  of  the 
former. 


FOOD  PRESERVATION  309 

The  conditions  inimical  to  the  development  of  bacteria  are  those 
which  may  be  adapted  to  the  preservation  of  food,  i.  e.,  sterilization. 

Ferments  and  putrefactive  germs  require  for  their  activity  a  fair 
degree  of  moisture,  a  moderately  warm  temperature,  which  for  many 
putrefactive  germs  ranges  between  60°  and  100°  F.,  while  certain 
germs  must,  in  addition,  have  free  oxygen  derived  from  the  atmos- 
pheric air. 

The  principal  means  employed  for  preserving  food  are: 

I.  Drying.  II.  Smoking.  III.  Salting.  IV.  Freezing.  V.  Ke- 
frigeration.  VI.  Sterilization.  VII.  Exclusion  of  Air  —  Canning. 
VIII.  Addition  of  Antiseptic  and  Preservative  Substances. 

I.  Drying. —  Is  discussed  under  Food  Concentration  (p.  305). 

II.  Smoking-. —  Smoking  is  the  preservation  of  meat  or  fish  by 
means  of  volatilized  creosote  and  other  substances  developed  from, 
wood  or  peat  smoke,  which  have  an  antiseptic  action.     It  is  chiefly 
applied  to  beef,  tongue,  ham,  bacon,  and  fish.     The  meat  or  fish  is 
hung  in  a  confined  chamber  and  saturated  with  wood  smoke  for  a 
long  time,  so  that  it  absorbs  a  small  percentage  of  antiseptic  ma- 
terials, the  fat  is  prevented  from  becoming  rancid  and  the  albumin 
from  putrefying.     The  smoking  is  commonly  employed  after  salting 
and  in  connection  with  drying.     Painting  the  surface  of  meat  with  a 
solution  of  wood  creosote  in  vinegar  has  the  same  preservative  action. 

The  outer  surface  of  meat,  such  as  ham  or  bacon,  preserved  by 
smoking  becomes  considerably  drier  and  tougher  than  the  interior, 
but  the  latter  is  not  made  tough  by  the  smoking  if  it  was  originally 
tender.  The  digestibility  of  hams  is  enhanced  by  smoking. 

The  process  of  smoking  is  applied  to  fish  upon  a  very  large  scale, 
and  in  many  instances,  as  in  smoked  mackerel,  herring,  and  salmon, 
while  the  flavor  is  different  from  that  of  the  fresh  fish,  it  is  agree- 
able. 

III.  Salting. —  The  process  of  salting  is  a  primitive  but  desirable 
method  of  preserving  meat  and  fish.     Salted  meat  usually  becomes 
pale  from  the  action  of  the  salt  upon  the  haemoglobin  contained  in  the 
blood  vessels  of  the  muscle  fiber.     The  addition  of  a  little  saltpeter 
helps  to  preserve  the  original  reddish  color  of  salted  meat.     Salt 
absorbs  moisture  from  food,  dries  and  preserves  it. 

Brine,  a  strong  solution  of  common  salt,  may  be  used  temporarily 
to  preserve  meat  and  other  substances.  The  Chinese  have  long  prac- 
ticed the  art  of  preserving  fruits,  roots,  and  flowers  in  it.  Corned 
beef  is  made  by  soaking  the  meat  for  some  da}rs  in  such  a  solution. 
The  brine  acts  upon  the  muscular  tissue  and  toughens  it.  Brine, 
concentrated  by  long-continued  use,  has  been  known-  to  acquire 


310  FOOD   PREPARATION   AND   PRESERVATION 

poisonous  properties  from  changes  in  the  organic  matter  which  has 
passed  into  it  from  the  meat.  The  process  of  soaking  in  brine  causes 
much  of  the  extractives  and  natural  salts  of  the  meat  to  osmose  out 
from  it,  and  the  loss  of  organic  material  and  salts  occurring  in  this 
way  has  been  estimated  by  Liebig  and  Parkes  as  equal  to  fully  one- 
third,  for  myosin  itself  is  soluble  in  strong  salt  solution.  For  these 
reasons  salted  meats  require  prolonged  cooking.  Salt  meat  is  drier, 
less  digestible,  and  slightly  less  nutritious  than  fresh  meat. 

IV.  Freezing. —  Food  may  be  kept  in  a  frozen  condition  almost  in- 
definitely. On  being  thawed,  it  should  be  cooked  immediately,  other- 
wise decomposition  may  set  in  at  once,  and,  excluding  milk  and  cream, 
food  is  not  easily  eaten  in  a  frozen  state,  except  by  the  northern 
Eskimos. 

Meat  and  fish  may  be  kept  many  days  in  blocks  of  ice  without  much 
loss  in  flavor,  but  vegetables  are  not  as  good  after  freezing. 

In  1867  Dr.  Carl  von  Baer  reported  the  discovery  in  arctic  Siberia 
of  a  frozen  mammoth,  the  meat  of  which  was  preserved.  As  this 
animal  has  been  extinct  since  the  days  of  prehistoric  man,  it  afforded 
an  illustration  of  the  marvelous  preservative  power  of  intense  cold. 
Another  such  animal  was  found,  in  1799,  being  eaten  by  wolves  in 
Siberia. 

In  1861  the  entire  bodies  of  three  Swiss  guides,  who  forty-one 
years  before  had  been  buried  by  an  avalanche  over  the  Glacier  de 
Boissons,  were  found  in  a  state  of  excellent  preservation. 

In  freezing  meat  for  export  it  is  subjected  to  a  temperature  of 
about  20°  F.  below  zero.  When  quite  hard  the  carcass  is  sewn  in 
cotton  cloth  and  placed  in  a  refrigerating  chamber  on  shipboard. 

Meat  actually  frozen  should  be  cooked  as  soon  as  it  is  thawed, 
and  meat  thus  preserved  is  better  cooked  by  roasting  than  boiling, 
unless  it  has  been  thawed  imperfectly,  in  which  case  the  central 
portion  may  remain  frozen  after  the  external  layers  have  begun  to 
cook,  and  when  the  latter  are  thoroughly  roasted,  the  inside  may 
be  found  almost  raw.  Frozen  meat  loses  10  per  cent  of  its  nutritive 
value  in  cooking.  Such  meat  has  been  transported  in  fresh  condition 
as  far  as  fifty  miles  inland  in  the  Philippines. 

Y.  Refrigeration. —  The  process  of  refrigeration  or  "  cold  storage  " 
preservation  does  not  involve  the  actual  freezing  of  meat,  fish,  eggs, 
fruits,  or  vegetables,  but  implies  their  preservation  in  chambers  at  a 
temperature  which  is  maintained  but  a  few  degrees  above  the  freez- 
ing point.  Tin's  causes  somewhat  less  alteration  than  freezing.  From 
the  purely  epicurean  standpoint,  both  freezing  and  refrigeration  of 
all  foods  deprive  them  of  much  natural  delicacy  of  flavor. 


FOOD   PRESERVATION 

The  cold  is  artificially  generated,  and  beef,  fish,  fruits,  and  vege- 
tables are  now  successfully  transported  for  thousands  of  miles  in 
refrigerator  cars  and  rooms  fitted  for  the  purpose  on  steamships. 

The  refrigerating  processes  applied  to  the  preservation  of  meat, 
etc.,  are  several.  In  most  of  them  the  reduction  of  temperature  of 
the  meat  is  maintained  by  cold  air  and  not  by  contact  with  ice. 

One  method  consists  in  the  adaptation  of  the  principle  that  com- 
pressed air  on  expanding  derives  the  energy  for  its  expansion  from 
heat,  which  it  abstracts  from  all  surrounding  bodies.  The  liberation 
of  strongly  compressed  air,  therefore,  produces  intense  local  cold  in 
its  immediate  vicinity.  The  air  is  originally  compressed  by  a  force- 
pump,  and  the  heat  which  is  developed  by  the  compression  is  re- 
moved by  a  circulating  stream  of  cold  water.  The  cooled  compressed 
air  is  then  liberated  with  the  effect  described.  Other  apparatus  is 
constructed  on  the  principle  of  ice  machines,  which  are  operated  by 
evaporating  ammonia,  which  produces  extreme  cold. 

The  keeping  of  meat  by  refrigeration  is  rapidly  superseding  the 
canning  process  for  this  kind  of  food,  over  which  it  has  many  decided 
advantages.  Between  15  and  20  per  cent  of  all  the  mutton  eaten 
in  England  is  thus  brought  from  New  Zealand  and  the  Eiver  Platte. 

In  time  of  war  refrigerated  dressed  beef  may  be  supplied  to  troops 
in  lieu  of  the  former  practice  of  trying  to  follow  them  with  cattle 
on  the  hoof,  or  furnishing  only  salt  meat. 

The  cold  storage  of  fowl  and  game  should  be  preceded  by  remov- 
ing ("drawing")  the  viscera,  otherwise  decomposition  products  are 
liable  to  taint  the  meat,  alter  the  flavor  and  disorder  digestion. 

When  fruits  are  kept  in  cold  storage  at  31°  to  23°  F.,  their  ripening 
is  checked,  as  well  as  development  of  any  fungous  growths. 

VI.  Sterilization. —  By  sterilization  of  food  is  meant  the  process  of 
rendering  it  germ-free  by  heat,  and  it  includes  the  preservation  of 
such  food  in  sterilized  vessels.     Practically  all   thoroughly   cooked 
food  is  for  the  time  being  "sterilized,"  and  overdone  meat  keeps 
longer  than  underdone  meat,  for  if  the  outer  layers  are  firmly  coag- 
ulated and  dried  by  the  heat  of  boiling  or  roasting,  they  form  an 
envelope  which  is  less  pervious  to  atmospheric  air  and  germs. 

VII.  Exclusion   of  Air. —  Exclusion  of  air  and  consequently  of 
germs  from  contact  with  food  is  accomplished  not  only  in  the  process 
of  canning,  but  by  such  means  as  varnishing  or  covering  it  with 
substances  which  are  comparatively  impermeable,  as  in  the  case  of 
varnishing  eggs,  covering  fish  with  oil,  or  pate  de  foie  gras  with  lard. 

Eggs  undergo  decomposition  from  the  entrance  of  air  and  germs 
through  their  shells,  and  this  process  may  be  prevented,  sometimes 


312  FOOD   PREPARATION   AND  PRESERVATION 

for  several  years,  by  covering  fresh  eggs  with  almost  any  substance 
which  is  more  impermeable  than  their  shells,  such  as  gum,  fat,  but- 
ter, oil,  beeswax,  or  fresh  milk  of  lime.  The  sawdust  or  salt  in 
which  eggs  are  commonly  packed  serves  the  double  purpose  of  in- 
suring safety  in  transportation  and  excluding  to  some  degree  the  air. 
Similarly  meat  may  be  preserved  by  coating  it  with  paraffin,  gelatin, 
collodion,  or  layers  of  powdered  charcoal  or  of  lard  after  the  man- 
ner of  potted  meats.  Beef  has  been  sent  in  good  condition  from 
Australia  to  England  by  dipping  it  into  hogsheads  of  melted  fat,  in 
which  it  was  left  after  the  fat  cooled  and  solidified.  The  preserva- 
tion of  meats  in  air-tight  skins,  like  sausages,  has  long  been  practiced. 

When  food  is  preserved  by  any  of  these  methods  care  should  be 
exercised  to  have  it  perfectly  fresh  at  first  and  to  drive  off  by 
heat  any  air  present  in  the  food  itself  or  its  containing  vessel. 

Canning. —  Frangois  Appert  first  employed  the  process  of  her- 
metically sealing  fruit  to  preserve  it  from  the  oxygen  of  the  air. 
It  is  now  known,  however,  that  many  putrefactive  bacteria  are 
anaerobic,  and  that  the  food  must  be  sterilized  thoroughly  before 
the  can  is  closed.  This  should  be  done  by  heat,  but  since  it  may  also 
be  accomplished  by  the  addition  of  antiseptics,  the  introduction  of 
the  latter  is  practiced  by  unscrupulous  manufacturers. 

The  process  of  canning  meat,  fruit,  or  vegetables  is  conducted  as 
follows :  The  fresh  food  is  placed  in  clean  new  tin  cans,  filling  them 
as  completely  as  possible.  Lids  are  then  tightly  soldered  on  the 
cans,  leaving  a  minute  pinhole  opening  only  for  the  escape  of  air  and 
steam.  The  cans  are  then  immersed  in  a  bath  of  boiling  fluid,  such 
as  zinc-chloride  solution,  having  a  higher  boiling  point  than  the 
water  within  the  cans.  The  latter  boils,  expels  at  first  air,  then 
steam,  and  thoroughly  cooks  the  food,  making  it  aseptic.  Before 
the  cans  cool,  their  minute  openings  are  soldered. 

The  long  boiling  of  meat  in  this  manner  toughens  its  fibers  by 
hardening  the  syntonin.  Such  meat  is  apparently  tender,  but  in 
reality  it  is  not  very  digestible. 

To  avoid  the  necessity  of  cooking  food  at  a  high  temperature  in 
order  to  exclude  the  air,  various  modifications  in  the  process  of 
canning  are  employed.  One  of  these  —  McCall's  —  is  based  on  the 
disinfection  of  the  air  by  sodium  sulphite.  In  another  process  sul- 
phurous acid  and  nitrogen  are  used  to  replace  the  air. 

H.  W.  Wiley,  who  has  made  an  exhaustive  study  of  canned  foods, 
says,  in  an  instructive  report  on  Foods  and  Food  Adulterants,  made 
by  him  for  the  United  States  Department  of  Agriculture: 

"  All  manner  of  food  is  canned,  and     .     .     .     vegetables  out  of 


FOOD  PRESERVATION  313 

season  are  no  longer  a  luxury  of  the  rich.  ...  In  the  American 
grocery  pineapples  from  Singapore,  salmon  from  British  Columbia, 
fruit  from  California,  peas  from  France,  okra  from  Louisiana,  sweet 
corn  from  New  York,  string  beans  from  Scotland,  mutton  from 
Australia,  sardines  from  Italy,  stand  side  by  side  on  the  shelves." 

Wiley  thus  refers  to  the  economic  value  of  canned  foods: 

"  The  quantity  of  dry  food  material  in  canned  goods  varies  within 
wide  limits.  It  is  very  low  in  such  vegetables  as  string  beans,  aspara- 
gus, etc.,  and  quite  high  in  such  materials  as  canned  corn,  succo- 
tash, and  other  bodies  of  that  description.  The  lowest  percentage 
of  dry  matter  in  string  beans  of  American  origin  was  4.17.  In  other 
words,  in  buying  one  hundred  pounds  of  such  material  the  consumer 
purchases  95.83  pounds  of  water. 

"  Such  food  materials  must  be  regarded  in  the  light  of  luxuries  or 
condiments  rather  than  as  nutrients  to  support  a  healthy  organism. 
An  expenditure  of  ten  or  fifteen  cents  for  a  good  article  of  flour  or 
meal  will  procure  as  much  nutriment  for  a  family  as  the  investment 
of  three  or  four  dollars  in  canned  goods." 

Canned  beef  is  boiled  and  steamed  under  pressure  at  250°  F. 
It  loses  most  of  its  extractives  and  has  the  tastelessness,  therefore, 
of  meat  from  which  soup  has  been  made.  Vegetables  may  be  added 
to  improve  the  taste,  either  in  the  canning  process  or  subsequently. 

Vegetable  canned  foods  when  opened  are  readily  spoiled  by  yeast 
fungi.  (For  acute  poisoning  from  eating  canned  food  see  Ptomaine 
Poisoning,  and  Lead  Poisoning.) 

VIII.  Antiseptic  and  Preservative  Substances. —  The  use  of  anti- 
septic or  preservative  fluids  is  designed  to  prevent  the  activity  of 
germs  and  fermentation.  Sugar,  like  salt,  in  strong  solution  possesses 
decided  antiseptic  power,  and  hence  the  employment  of  strong  sirups 
for  the  preservation  of  fruits,  and  of  sugar  itself  in  making  candied 
fruits.  Other  harmless  preservative  materials  which  are  added  are 
oils,  chiefly  serviceable  for  keeping  fish,  and  vinegar  and  spirits  of 
wine  for  pickling  such  products  as  chilies,  tarragon,  and  shallot. 

Vinegar  is  used  to  preserve  oysters,  lobsters,  and  other  sea  food, 
as  well  as  cucumbers,  cauliflower,  onions,  peppers,  and  other  vege- 
tables, as  "pickles."  Spices,  mustard,  etc.,  are  usually  added. 

"  Soused "  fish,  such  as  mackerel,  are  immersed  in  mixtures  of 
cider  vinegar  flavored  with  cloves,  nutmeg,  parsley,  bay,  onions,  etc. 
After  being  "soused"  once  or  twice  the  food  is  heated  to  140°  F., 
flavoring  substances  are  added,  such  as  Worcestershire  sauce,  extract 
of  anchovy,  and  lemons,  and  the  whole  is  put  in  air-tight  jars. 

Among  the  materials  employed  for  preserving  foods  may  be  men- 


314  FOOD  PREPARATION   AND  PRESERVATION 

tioned  the  fumes  of  burning  sulphur  (sulphurous  acid),  acetic, 
salicylic  and  boric  acids,  borax,  sodium  benzoate,  formalin,  glycerin, 
weak  carbolic  acid,  bisulphite  of  calcium,  and  the  injection  into  the 
blood  vessels  of  meat  of  alum,  chloride  of  aluminum,  etc.  Sodium 
sulphite  is  added  to  preserve  chopped  meat  and  Hamburger  steak,  and 
a  mixture  of  borax,  niter,  and  salt  is  used  in  sausages. 

The  modern  use  of  chemical  food  preservatives  has  increased  so 
much  of  late  years  as  to  require  restriction  by  legislation.  Many 
chemical  preservatives  from  their  lack  of  odor,  color  or  taste  as 
applied  to  food  are  not  easily  detected  by  the  consumer.  Their  use, 
moreover,  lends  a  false  security  and  leads  to  lack  of  proper  cleanliness 
and  careful  selection  and  handling  of  foods.  The  effects  upon  the 
health  of  the  consumption  of  these  chemicals  has  been  the  subject 
of  recent  exhaustive  research  by  H.  W.  Wiley,  who  experimented 
with  a  number  of  soldiers  and  others,  who  volunteered  their  services 
and  who  became  known  as  "  the  Poison  Squad."  His  results  (pub- 
lished in  Bulletin  84,  parts  I,  II,  III,  U.  S.  Dept.  of  Agriculture, 
1906)  are  summarized  briefly  as  follows: 

Salicylic  acid  "  as  a  preservative  increases  the  solubility  and  ab- 
sorption of  the  food  in  the  alimentary  canal,"  but  "the  tissues  are 
broken  down  more  rapidly  than  they  are  built  up,  and  thus  the 
normal  metabolic  processes  are  interfered  with  in  a  harmful  way," 
and  the  body  weight  is  diminished,  although  the  food  eaten  may  be 
increased.  The  drug  increases  the  acidity  of  the  urine  and  gives  rise 
to  faint  albuminuria,  for  fully  one-half  of  the  drug  ingested  is  ex- 
creted unaltered  in  the  urine.  The  solids  of  the  feces  are  lessened 
and  abdominal  discomfort  and  overworked  kidneys  are  the  result 
of  its  protracted  use  in  food.  These  effects  are  more  pronounced 
with  salicylic  acid  than  with  sodium  salicylate. 

The  French  Commission  of  Public  Hygiene  made  an  exhaustive 
investigation  of  the  subject  of  adulteration  of  bottled  beer,  cider, 
milk,  grape  juice,  and  other  aliments  with  salicylic  acid,  which  is 
mainly  added  to  prevent  decomposition.  They  reported  that  its  daily 
use  in  the  quantities  employed  for  preservation  is  not  harmful  to 
healthy  persons,  but  if  renal  or  hepatic  disease  exist  it  may  become 
so,  for  under  these  conditions  it  is  not  promptly  eliminated.  Used  in 
any  considerable  quantity,  it  in  time  produces  anasmia,  as  it  does  in 
rheumatism,  but  it  is  constantly  employed  medicinally  in  doses  far 
exceeding  the  quantity  likely  to  be  ingested  with  food,  and  without 
harmful  effect. 

Boric  acid,  sodium  benzoate  and  borax  or  sodium  biborate  are  used 
in  preservation  of  milk,  beer,  meats,  sausage,  and  of  butter  when 


FOOD  PRESERVATION  315 

destined  for  distant  transportation.  Neither  of  these  chemicals  is 
harmful  if  taken  in  very  small  amount,  and  not  continuously.  One- 
half  per  cent  is  the  quantity  rarely  exceeded  as  a  preservative,  and  one 
is  not  likely  to  consume  more  than  half  a  gram  (~i^  grains)  a  day. 
About  three-fourths  of  all  the  butter  imported  into  England  contains 
boric  acid,  and  some  samples  contain  40  grains  to  the  pound. 

When  either  borax  or  boric  acid  is  ingested  with  food  in  excess,  80 
per  cent  of  these  substances  is  excreted  in  the  urine  and  20  per  cent  in 
the  perspiration.  Existing  albuminuria  is  increased  by  their  use,  body 
weight  is  lost,  nitrogen  elimination  is  inhibited,  and  more  phosphoric 
acid  than  normal  is  eliminated.  Prof.  B.  H.  Chittenden  and  William 
J.  Gies,  after  elaborate  experiments  upon  animals,  conclude  as  fol- 
lows: Doses  of  borax  up  to  5  grams  (77  grains)  per  diem,  con- 
tinued for  some  time,  do  not  disturb  proteid  metabolism  or  general 
nutrition.  In  larger  doses  borax  retards  proteid  and  fat  assimilation 
and  increases  the  weight  of  feces.  Very  large  doses  cause  nausea, 
vomiting,,  mucous  diarrhoea,  and  lessen  the  urine  secretion  (through 
which  borax  is  eliminated).  Boric  acid  in  doses  amounting  to  10  or 
15  grains  per  diem,  unless  long  used,  does  not  affect  nutrition  or 
proteid  metabolism;  it  does  not  affect  the  volume  of  urine  or  irritate 
the  alimentary  canal.  Neither  drug  controls  intestinal  putrefaction. 

A  method  of  meat  preservation  has  been  introduced  by  a  Mr. 
Jones  in  England,  which  consists  of  injecting  the  animal  the  mo- 
ment after  it  is  killed  with  a  solution  of  borax,  which  is  so  uniformly 
distributed  through  the  circulation  to  all  the  fibers  of  the  meat  that 
only  a  very  small  quantity  of  the  antiseptic  need  be  employed. 

Dr.  Wiley  having  reported  adversely  on  the  use  of  sodium  benzoate 
as  a  food  preservative,  as  a  result  of  experimentation  upon  the  "  Poison 
Squad  "  above  referred  to,  and  the  matter  having  excited  much  con- 
troversy in  reference  to  the  prohibitive  sections  of  the  Pure  Food  Act 
of  Congress,  a  special  Commission  was  appointed  by  the  National 
Government  to  experiment  and  report  upon  this  question.  The  re- 
port, signed  by  Professors  Ira  Eemsen,  Eussell  H.  Chittenden,  John  H. 
Long  and  Christian  A.  Herter  (known  as  the  Eeferee  Board),  gives 
the  following  main  conclusions : 

First:  Sodium  benzoate  in  small  doses  (under  0.5  gram  per  day) 
mixed  with  the  food  is  without  deleterious  or  poisonous  action  and 
is  not  injurious  to  health. 

Second:  In  large  doses  (up  to  4  grams  per  day)  mixed  with  the 
food  it  has  not  been  found  to  exert  any  deleterious  effect  on  the 
health.  There  were  slight  modifications  in  certain  physiological 
processes,  the  exact  significance  of  which  is  not  known. 


316  FOOD   PREPARATION   AND  PRESERVATION 

Third :  Its  admixture  with  food  in  large  doses  has  not  been  found 
to  impair  the  quality  or  nutritive  value  of  food. 

It  is  strange  that  if  sodium  benzoate  is  as  deleterious  to  health  as 
has  been  claimed,  .that  medical  literature  contains  no  reference  to 
cases  of  chronic  poisoning  by  its  use.  On  the  contrary,  in  the  pre- 
antitoxine  days  it  was  much  used  in  the  treatment  of  diphtheria. 
The  National  Dispensatory  refers  to  such  use  in  daily  dosage  of  120 
grains  to  a  child  of  3  years,  and  360  grains  to  adults.  Since  the  in- 
troduction of  antitoxine,  however,  the  use  of  the  drug  has  become 
obsolete. 

Sulphurous  acid  gas  in  solution  and  sulphites  are  alike  moderately 
injurious  as  preservatives.  Where  these  substances  are  used  sulphur 
metabolism  is  increased  in  the  body,  so  that  more  is  eliminated  in  the 
urine  and  feces  than  is  digested.  The  kidneys  are  overworked  and 
albuminuria  may  occur.  Anaemia  is  produced  and  the  body  loses 
weight.  There  is  diminished  food  absorption  and  urea  excretion. 

"  Embalmed  beef"  This  term  is  applied  to  meat  which  has  been 
coated  with  a  preservative  antiseptic  wash  of  some  sort.  A  solution 
of  boric  acid  is  sometimes  employed,  but  formalin  is  used  more  often. 
Flies  avoid  the  coating  and  do  not  deposit  putrefactive  germs  upon  it. 

Formaldehyd,  or  formalin,  is  a  strong  antiseptic.  It  is  not  espe- 
cially harmful  in  moderate  doses,  but  Halliburton,  of  London,  has 
shown  that  it  is  especially  active  in  inhibiting  the  action  of  the  nor- 
mal digestive  ferments.  Given  in  milk  it  is  injurious  to  infants. 

Glycerin  has  been  used  as  a  preservative,  but  it  cannot  be  employed 
in  any  quantity  on  account  of  its  aperient  action. 

It  is  true  of  practically  all  of  these  latter  substances  that  food 
preserved  by  them  if  used  in  great  excess  or  for  too  long  a  time  is  apt 
to  endanger  the  normal  digestive  functions,  besides  being  somewhat 
less  nutritious  and  more  tasteless  than  other  food. 

SUBSTITUTES  FOR  FOOD 

Men  are  often  placed  under  conditions  in  which,  from  poverty  or 
exposure,  sufficient  quantities  of  food  cannot  be  obtained.  Under 
these  circumstances,  the  craving  of  hunger  may  be  diminished  and 
the  actual  tissue  waste  may  be  retarded  by  the  substitution  of  cer- 
tain mild  stimulants  and  beverages.  Tea,  coffee,  and  tobacco  all 
possess  moderate  action  in  this  respect,  and  alcohol,  under  such  con- 
dition?, is  both  a  stimulant  and  a  food.  The  natives  of  various  bar- 
barous or  somicivilizecl  countries,  while  performing  long  feats  of 
endurance,  such  as  marching,  being  often  unable  to  obtain  sufficient 


QUANTITY    OF   FOOD    REQUIRED  317 

food  with  regularity,  make  use  of  a  variety  of  food  substitutes. 
Among  these  may  be  mentioned  betel  nut,  kola  nut,  Siberian  fungus, 
the  cocoa  leaf,  and  pepperwort,  which  are  chewed  from  time  to  time ; 
hasheesh  and  opium,  which  are  both  eaten  and  smoked;  mate,  and 
various  forms  of  alcoholic  fermented  drinks.  All  these  substances 
are  used  to  enable  men  to  prolong  periods  of  fasting,  either  with  or 
without  exertion. 


According  to  Wiley,  a  fair  average  of  the  total  quantity  of  food 
required  each  day  for  maintenance  of  healthful  equilibrium  in  the 
adult  man,  measured  in  grams  (not  calories)  is  as  follows:  Moist 
food  =  2,500  to  3,000  grams ;  dry  material  =  550  to  650  grams  (453.5 
grams  =  1  Ib.  avoirdupois),  or  in  round  numbers  respectively  4  per 
cent  and  1  per  cent  of  the  body  weight. 

In  civilized  communities,  where  cooking  is  a  fine  art,  the  number 
and  variety  of  food  preparations  is  so  great  that  the  appetite  is.  often 
stimulated  beyond  the  requirements  of  the  system,  and  consequently 
more  food  is  eaten  than  is  necessary  or  desirable  to  maintain  the 
"  optimum  "  bodily  health  and  vigor. 

Persons  in  this  country  who  live  in  comfortable  circumstances 
often  eat  a  dozen  or  fifteen  ounces  of  solid  food  at  breakfast,  and 
again  at  luncheon,  and  perhaps  thirty  ounces  more  at  dinner,  making 
a  total  of,  say,  fifty-five  or  sixty  ounces,  to  which  are  added  only 
fifty  or  fifty-five  ounces  of  fluids.  This  is  about  a  third  more  than 
the  amount  of  solids  actually  needed,  forty  ounces  of  solid  food 
(which  equals  twenty-three  ounces  of  water-free  food)  being  a  fair 
average  for  the  daily  necessities  of  most  persons,  one-fourth  of  which 
should  be  animal  and  three-fourths  vegetable  food.  They  eat  too 
much  and  drink  too  little  fluid  in  proportion.  (See  Water,  p.  40.) 

Gluttony  results  in  overdevelopment  and  overwork  of  the  digestive 
apparatus.  The  stomach  and  bowels  become  enlarged,  the  liver  is 
engorged,  and  a  predisposition  is  established  to  degenerative  changes, 
fatty  heart,  etc.  (See  Overeating.) 

The  most  northern  Eskimos,  for  example,  who  often  eat  only  one 
meal  a  day  and  then  gorge  themselves  with  tough  meat,  develop 
big  jaws  and  distended  abdomens  (Cooke). 

Sir  Henry  Thompson  says  (Diet  in  Relation  to  Age  and  Activity)  : 
"  More  mischief  in  the  form  of  actual  disease,  of  impaired  vigor, 
and  of  shortened  life  accrues  to  civilized  man.  so  far  as  I  have 
observed  in  our  own  country  and  throughout  western  and  central 


318  FOOD   PREPARATION   AND   PRESERVATION 

Europe,  from  erroneous  habits  in  eating  than  from  the  habitual  use 
of  alcoholic  drink,  considerable  as  I  know  the  evil  of  that  to  be." 

The  quantity  of  food  required  to  maintain  the  body  in  vigor  de- 
pends upon  the  following  conditions: 

1.  Climate  and  season.  2.  Clothing.  3.  Occupation,  work,  and 
exercise.  4.  The  state  of  individual  health.  5.  Age.  6.  Sex.  7. 
Size  of  body.  8.  Body  weight.  (For  the  Quantity  of  Food  in  Ill- 
ness, see  p.  445.) 

1.  Climate  and  Season. —  Much  has  been  written  about  the  need 
of  man  changing  his  diet  when  he  removes  from  one  climate  to  an- 
other, in  the  belief  that  the  natives  always  eat  the  kind  of  food  best 
adapted  to  the  climate  in  which  they  live.  This  is  superficial  reason- 
ing, and  too  much  importance  is  attached  to  the  relations  of  climate 
to  diet  per  se.  As  a  matter  of  fact,  the  natives  of  a  country  eat 
what  they  can  obtain  easiest,  or  what  their  habits  and  mode  of  life 
have  accustomed  them  to  in  the  struggle  for  the  survival  of  the  fittest. 
"  Climate  affects  diet  mainly  by  the  supply  it  affords  "  (Chambers). 

"  The  national  dietary  is  determined  largely  by  the  climate  and 
nature  of  the  available  soil,  and  among  civilized  communities  it  is 
largely  modified  as  facilities  for  commerce  and  interchange  of  food 
products  are  increased. 

"  Maritime  people  naturally  derive  much  nitrogenous  food  from 
the  sea,  as  fish,  molluscs,  crustaceans,  etc.  Among  the  residents  of 
the  far  North  albuminous  and  fatty  diet  predominates,  and  the 
coarser  cereals  —  barley,  rye,  oats,  etc. —  being  more  hardy,  pre- 
dominate in  their  food.  Barley  grows  the  farthest  north  of  all  the 
cereals"  (Clark). 

The  Hindu  subsists  mainly  upon  rice,  one  of  the  simplest  types 
of  farinaceous  food,  and  he  derives  his  nitrogen  from  corn  and  len- 
tils. He  must  consequently  eat  a  large  bulk  of  food  in  order  to 
obtain  sufficient  nitrogen  for  the  needs  of  the  system;  his  digestive 
organs  enlarge,  and  he  finds  the  means  of  stimulating  them  by  the 
free  use  of  condiments  of  various  sorts.  Bulky  and  fibrous  vegetable 
food  distends  the  alimentary  canal.  The  natives  of  very  hot  coun- 
tries live  mainly  upon  vegetable  and  starchy  foods,  eating  cereals, 
green  vegetables,  and  pulpy  fruits  which  contain  water,  salts,  and 
acids  in  abundance,  which  are  cooling  and  refreshing.  As  a  rule,  they 
eat  less  animal  food  than  do  the  natives  of  temperate  and  arctic  re- 
gions, nor  do  they  require  fats  in  excess,  although  they  take  some  fats 
and  oils. 

While  these  general  statements  apply  to  a  majority  of  mankind, 
they  arc  by  no  means  without  exception,  and  it  should  not  be  argued 


319 

that  because  a  tribe  eats  the  only  food  which  Nature  has  provided, 
they  could  not  live  equally  well  in  their  own  climate  upon  other  food, 
if  they  could  obtain  it,  a  fact  amply  demonstrated  in  the  history 
of  the  North  American  Indians.  Far  from  depending  solely  upon 
vegetable  food,  most  savage  tribes  living  in  the  torrid  zone  eat  meat 
ravenously  when  they  can  get  it,  and  often  prefer  it  in  an  advanced 
stage  of  decomposition. 

The  New  Zealander  and  South  Sea  Islander  choose  a  varied  diet  of 
fish,  eggs,  roots,  seeds,  berries,  seaweeds,  and  meat  if  obtainable 
(see  p.  36). 

As  pointed  out  by  Chambers,  the  Pampas,  who  eat  flesh  and  drink 
water  only,  thrive  on  hot  arid  plains,  and  so  do  the  Nubian  Arabs, 
while  the  peasants  of  northern  Norway  and  southern  Spain  live  alike 
almost  entirely  on  breadstuffs  without  meat.  He  says  that  "  the  im- 
mediate transition  from  a  purely  animal  to  a  purely  vegetable  diet, 
though  borne  by  the  individual,  is  fatal  to  the  race,"  and  "the 
best  diet  in  the  abstract  is  a  mixed  diet,  and  mixed  in  the  proportion 
selected  by  the  experience  of  most  civilized  nations,  and  it  is  also 
best  for  the  individual  who  is  accustomed  to  it  to  adhere  to  under 
whatever  sky  he  may  be  wandering."  In  changing  residence  from 
one  extreme  of  climate  to  another  it  is  not  advisable  to  alter  the 
diet  too  suddenly,  and  much  more  depends  upon  the  previous  habits 
and  occupation  of  the  individual  than  upon  external  tempera- 
ture. 

Meat  eaters  find  it  easier  to  adopt  quickly  another  form  of  diet 
than  vegetarians.  The  Dominican  friars  deteriorated  so  much  in 
health  in  the  British  climate  that  they  were  gbliged  while  resident 
in  England  to  obtain  special  dispensation  allowing  them  to  eat  meat 
four  times  a  week. 

English  soldiers  transported  to  India  or  Africa  are  not  required 
to  become  exclusive  vegetarians :  and  the  French  in  Africa  or  Panama 
have  done  best  upon  a  mixed  4iet.  In  the  United  States  Surgeon 
General's  report  for  1900  the  statement  is  made  that  "  experience 
in  the  Philippines  has  shown  that  though  it  is  undoubtedly  true  that 
while  leading  quiet  lives  men  eat  less  in  a  tropical  climate  than  in 
a  temperate  or  cold  climate,  and  particularly  of  meat  or  fatty  sub- 
stances, our  soldiers  during  the  active  operations  of  last  year  have 
shown  no  marked  tendency  to  lessen  the  quantity  of  fresh  meat  eaten. 
Exhausting  labors  and  fatigues  with  corresponding  wear  and  tear  of 
the  muscular  system  requires  a  liberal  meat  issue,  which  the  soldier 
uses  with  satisfaction  and  advantage." 

"  Well-clad  and  sheltered  soldiers  require  less  rations  than  poorly 


320  FOOD  PREPARATION  AND  PRESERVATION 

clad  men  exposed  to  the  weather  —  a  good  thing  to  know  in  times 
of  great  privation  "  (Woodruff). 

Men  often  become  involuntary  vegetarians  while  traveling  in  hot 
climates  from  inability  to  procure  meat,  and  may  partially  starve 
themselves  from  lack  of  appetite  for  monotonous  food,  variety  being 
unobtainable.  This  leads  them  to  resort  to  strong  condiments,  spices, 
curry,  etc.,  to  stimulate  the  appetite. 

Many  persons,  especially  those  past  middle  life  and  persons  with 
a  tendency  to  corpulency,  find  that  during  the  heat  of  the  summer 
season,  and  especially  during  the  prevalence  of  "heat  waves,"  they 
are  in  much  better  health  when  they  abstain  from  hot  soups,  fat, 
and  meat,  and  take  little  animal  food  of  any  kind.  The  total 
quantity  of  food  eaten  may  advantageously  be  reduced  at  this  time 
of  the  year  as  much  as  one-sixth,  or  even  one-fourth.  Most  persons 
find  this  out  as  a  matter  of  individual  experience;  but  there  are 
others  who  should  be  directed  especially  in  the  matter,  and  the  rule 
applies  to  infants  as  well  as  adults. 

The  breakfast  hour  is  often  made  half  an  hour  or  an  hour  earlier 
in  summer  than  in  winter  to  advantage. 

The  thirst  engendered  by  living  in  hot  climates  is  conducive  to 
excessive  drinking,  and  as  the  water  is  often  unhealthful,  an  addi- 
tional excuse  is  often  made  for  drinking  too  much  liquor.  By  these 
means  the  foundations  for  hepatic  and  renal  troubles,  such  as  cirrhosis, 
and  Bright's  disease  are  often  laid.  On  this  account,  in  very  hot 
climates  strong  alcoholic  drinks  ought  especially  to  be  avoided.  In 
India  they  uniformly  disagree,  and  lighter  beverages,  such  as  beer  and 
wines  should  be  taken. very  sparingly;  but  there  is  no  objection  to  tea, 
coffee,  and  chocolate. 

The  diet  in  winter  should  comprise  both  more  nitrogen  and  more 
carbon  than  in  summer. 

Cold,  bracing  atmosphere  stimulates  the  appetite,  circulation  and 
respiration,  and  consequently  the  rate  of  oxidation  processes.  It 
tempts  one  to  exercise  vigorously,  and  hence  demands  a  larger  con- 
sumption of  food  for  fuel.  A  hot  climate  or  season,  with  enervating, 
moist  air,  disposes  to  languor  and  inactivity,  and  diminishes  the  ap- 
petite as  well  as  the  need  for  food. 

Dr.  Frederick  A.  Oooke,  physician  to  the  Peary  expedition  to 
the  north  pole  in  1890-1892,  wrote  me  in  reference  to  the  quantity 
and  quality  of  food  required  in  the  coldest  climate  known,  as  fol- 
lows : 

"  The  members  of  our  expedition  took  very  few  forced  marches 
in  low  temperatures.  The  one  over  the  interior  of  Greenland  was 


QUANTITY  OF  FOOD  REQUIRED  321 

undertaken  at  the  time  of  year  when  the  thermometer  ranges  from 
5°  F.  below  zero  to  40°  above. 

"  The  quantity  of  food  consumed  per  man  every  twenty-four  hours 
upon  this  expedition  was  as  follows : 

Pemmican    1%  pound. 

Bacon,  fat    6       ounces. 

Powdered  pea  soup 2 

Dry  ship  biscuits   12 

Condensed   milk    3  " 

"  A  quart  of  tea  with  perhaps  a  pint  of  water  was  our  only  drink, 
but  we  had  no  drink  through  the  day  while  on  the  march,  and  often 
were  unable  to  secure  more  fluid  than  two  cups  each  morning  and 
night.  The  pemmican  was  composed  of  dried  beef  and  beef  tallow, 
half  and  half,  a  few  currants,  and  a  little  sugar,  but  no  salt.  On 
several  expeditions  during  the  spring  of  1892,  while  the  thermometer 
ranged  from  20°  to  40°  F.  below  zero,  the  members  of  the  party 
always  consumed  large  quantities  of  food.  This  was  not,  however, 
until  they  had  been  out  two  or  three  days,  when  the  amount  of 
food  which  they  could  devour  seemed  almost  unlimited.  There 
was  no  time  that  we  craved  fat.  We  enjoyed  the  pemmican  im- 
mensely, but  that  was  because  we  had  nothing  else.  During  the 
extreme  cold  weather,  while  in  the  field,  we  took  more  kindly  to 
fats,  but  never  in  preference,  to  other  foods.  Canned  meats,  for 
some  unexplained  reason,  were  soon  in  disfavor,  for  the  variety  and 
character  of  the  food  seemed  to  be  of  very  little  consequence ;  indeed, 
our  appetites  were  such  that  we  were  ready  to  eat  anything  and  every- 
thing placed  before  us.  We  were,  however,  always  liberally  sup- 
plied with  hydrocarbons,  and  I  believe  had  this  not  been  the  case,  a 
demand  for  them  would  soon  have  arisen,  for  the  most  valuable  food 
for  a  polar  expedition  is  composed  largely  of  hydrocarbons. 

"  The  most  important  articles  of  diet  for  a  polar  expedition  we 
found  to  be  pemmican,  cranberry  sauce,  tea,  coffee,  chocolate,  pre- 
served milk,  sugar,  ham,  cheese,  bacon,  oleomargarine,  lard,  pickles, 
lime  juice,  dried  fish,  beef-soup  tablets,  wheat,  corn,  rye  flour,  rice, 
hominy,  oatmeal,  dried  vegetables,  and  a  liberal  supply  of  all  kinds 
of  canned  vegetables,  particularly  canned  tomatoes,  peas,  beans,  corn, 
canned  soups,  and  dried  fruits.  Lime  juice  was  not  served  regularly 
to  the  members  of  the  expedition,  and  I  think  nothing  is  to  be  gained 
by  so  doing.  For  some  of  the  members  of  the  party  it  was  decidedly 
injurious,  but  others  called  for  it  occasionally  as  a  refreshing  drink." 

2.  Clothing  and  Food. —  Abundant  clothing  in  a  cold  climate  con- 
serves the  body  heat,  and  less  food  is  therefore  required  to  maintain 

life  than  if  the  body  is  scantily  clad. 
23 


322  FOOD  PREPARATION  AND  PRESERVATION 

3.  Exercise  and  Food. —  Exercise  and  muscular  work  also  promote 
oxidation  in  the  tissues  and  augment  waste  production  from  the  mus- 
cles.    This  waste  must  be  replaced,  and  energy  supplied  for  work  by 
additional  consumption  of  food.     Outdoor  work  demands  more  food 
than  indoor  work,  and  mental  labor  less  than  physical.     Where  men 
are  fed  upon  a  carefully  regulated  diet  —  as  in  prisons  —  it  is  found 
that  those  who  are  performing  hard  labor  require  about  one-fifth 
more  solid  food  than  the  others. 

4.  General  Health  and  Food. —  The  state  of  health  of  the  indi- 
vidual greatly  modifies  the  amount  of  food  required  both  indirectly, 
through  influencing  exercise  and  work,  and  directly,  by  the  local  con- 
dition of  the  digestive  system. 

Feeble  and  inactive  persons  may  live  on  a  third  or  less  of  the 
ordinary  ration.  Patients  having  chronic,  purulent  discharges,  such 
as  come  from  old  sinuses,  empyema,  and  tubercular  abscesses,  need 
large  quantities  of  food  —  if  they  can  digest  it  —  to  maintain  their 
strength  against  the  constant  drain  on  their  systems. 

The  nursing  mother  should  have  abundant  food,  for  she  must  eat 
for  two. 

5.  Age  and  Food. —  The  age  of  the  individual  not  only  modifies 
the  absolute  amount  of  food  required,  but  also  the  relative  quantity 
in  proportion  to  body  weight.     In  the  first  year  of  life  the  infant 
grows  six  or  eight  inches,  and  at  the  end  of  a  twelvemonth  it  should 
weigh  two  or  three  times  as  much  again  as  at  birth.     This  rapid 
growth  necessitates  a  relatively  larger  consumption  of  food  than  at 
any  other  period  of  life,  and  hence  the  child  is  fed  at  first  once  every 
two  hours,  and  later  every  three  hours.     During  the  second  year  the 
proportionate  growth  is  half  that  of  the  first  year,  and  during  the 
third  year  it  is  one-third  that  of  the  first.     After  the  third  year  the 
weight  and  growth  increase  more  uniformly,  but  the  child  still  should 
have  a  large  relative  quantity  of  food,  a  great  proportion  of  which 
should  be  tissue-forming  —  i.  e.,  protein. 

The  following  table  comprises  the  standards  adopted  by  the  United 
States  Department  of  Agriculture: 

One  7ncal  of  boy  14  to  16  years  of  age,  inclusive,  equivalent  to  0.8  meal  of 

man. 
One  meal  of  girl  14  to  1G  years  of  age,  inclusive,  equivalent  to  0.7  meal  of 

man. 
One  meal  of  child  10  to  13  years  of  age,  inclusive,  equivalent  to  0.6  meal  of 

man. 
One  meal  of  child  G  to  9  years  of  age,  inclusive,  equivalent  to  0.5  meal  of 

man. 
One  meal  of  child  2  to  5  years  of  age,  inclusive,  equivalent  to  0.4  meal  of 

man. 
One  meal  of  child  under  2  years  of  age  equivalent  to  0.3  meal  of  man. 


QUANTITY   OF   FOOD   REQUIRED  323 

The  rapidly-growing,  active  boy  oftens  eats  more  animal  food  than 
the  adult,  and  the  middle-aged  man  eats  more  than  the  aged.  A 
man  of  seventy  years  may  preserve  good  health  on  a  quantity  of  food 
which  would  soon  starve  his  grandson.  (This  topic  is  further  dis- 
cussed under  Age  and  Food,  p.  322.) 

6.  Sex  and  Food. — The  relation  of  sex  in  regard  to  food  affects 
the  quantity  rather  than  the  quality,  excepting  among  a  few  rude 
tribes  where  superstition  is  allowed  full  sway.  The  northern  Eskimos, 
for  instance,  have  a  belief  that  if  women  eat  eggs  they  cannot  become 
pregnant,  which  is  a  curious  contrast  to  the  reputation  for  aphrodisiac 
effects  which  this  food  has  among  civilized  people ! 

About  the  only  way  in  which  sex  affects  the  quality  of  food  con- 
sumed is  in  the  somewhat  greater  fondness  for  sweets  and  confec- 
tionery exhibited  by  females,  but  this  may  be  shown  to  be  due  more 
to  other  considerations  of  habit  and  custom  than  to  sex.  The  use 
of  tobacco  and  alcohol  by  many  men,  for  instance,  makes  them  care 
less  for  such  foods. 

Sex  influences  to  a  considerable  extent  the  quantity  of  food  consumed, 
but  allowance  should  be  made  for  totally  different  habits  of  life.  There 
are  many  women  who  eat  as  much  as  men,  but  the  majority  require 
less  food,  although  doing  the  same  work.  Under  equal  conditions 
in  penal  institutions  men  require  about  one-fifth  more  solid  food  than 
women.  Female  factory  operatives  eat  from  one-tenth  to  one-fifth 
less  food  than  men.  Prof.  Arthur  Goss  gives  the  equivalent  that  one 
meal  of  woman  averages  0.8  meal  of  man  at  moderate  muscular 
labor. 

Women,  on  the  average,  weigh  less  than  men,  take  less  exercise, 
work  less,  and  live  less  in  the  open  air,  and  hence  require  less  food. 
As  a  consequence  of  their  habits  of  life  they  are  more  liable  to  dys- 
pepsia and  constipation,  which  are  also  factors  in  reducing  the  quan- 
tity of  their  food  below  the  standards  for  men.  There  are  many 
exceptions  to  all  these  general  statements. 

Mrs.  E.  H.  Eichards,  as  the  result  of  observations  (Food  as  a 
Factor  in  Student  Life)  upon  130  young  women  students  at  the 
University  of  Chicago,  whose  average  weight  was  120  pounds,  gives 
the  following  table  of  food  consumption  in  grams  per  diem: 

Protein     120 

Fat    161 

Carbohydrates     402 

Total  .  659 


Potential  energy  in  calories    3,383 


324  FOOD  PREPARATION   AND  PRESERVATION 

Woman  with  little  muscular  work  demands  80  grams  protein,  and 
a  total  food  value  of  2,400  calories ;  at  moderate  muscular  work  woman 
requires  90  grams  protein  and  2,800  calories;  man  with  little  mus- 
cular work  requires  112  grams  protein  and  3,000  calories,  and  at 
moderate  muscular  work  125  grams  protein  and  3,500  calories. 

7.  Size  and  Food. — The  size  of  the  body  has  more  influence  than 
its  weight  upon  the  quantity  of  food  consumed.  ,  In  infant  feeding 
the  relationship  is  made  the  subject  of  careful  study   (see  Infant 
Feeding),    but    in    adults    there    is    more    variation.     As    a    gen- 
eral rule,  persons  of  large  frame  eat  in  proportion  to  their  size,  and 
vice  versa,  but  there  are  many  exceptions  familiar  to  all,  and  some 
very  corpulent  persons  are  very  abstemious  at  the  table.     Because 
most  persons  eat  more  than  they  really  need,  a  man  of  large  frame 
often  can  eat  less  than  one  of  small  size,  and  yet  have  plenty. 

Attempts  have  been  made  to  demonstrate  that  a  preponderance 
of  animal  or  vegetable  food  respectively,  or  of  some  particular  sys- 
tem of  diet,  influences  the  stature  of  men.  Of  course,  children  who 
receive  insufficient  food  or  food  poor  in  quality  may  be  half  grown, 
but  beyond  that  fact  theories  as  to  the  specific  influence  of  different 
classes  of  food  upon  the  development  of  the  body  are  founded  upon 
ignorance  of  the  natural  history  of  the  different  races  of  man.  The 
diet  of  Bushmen,  Australians,  and  Fuegians  presents  instructive  ex- 
amples of  tribes  with  respectively  large  or  small  bodies,  and  differ- 
ent diets,  demonstrating  that  "  it  is  not  quality  or  monotony  of  food, 
but  its  quantity  that  affects  development"  (Gerland).  The  Japanese 
having  followed  the  vegetarian  doctrines  of  Buddha  for  a  thousand 
years,  lately  have  been  increasing  their  meat  consumption  in  the 
hope  that  in  time  it  may  bring  the  height  of  their  bodies  up  to 
European  standards,  but  there  are  many  other  factors  concerned. 

8.  Body  Weight  and  Food. —  The  question  as  to  how  far  gain  or 
loss  in  the  body  weight  may  be  taken  as  an  indication  of  the  ap- 
propriateness of  any  diet  is  important.     In  prescribing  systems  of 
diet  for  many  diseases,  such  as  dyspepsia,  obesity,  diabetes,  phthisis, 
etc.,   it  is   desirable  to  have  the  patient  weighed  systematically  at 
least  once  a  week,  and  good  scales  are  very  useful  in  the  physician's 
office.     Care  should,  of  course,  be  observed  that  changes  in  clothing 
are  not  allowed  to  interfere  with  the  accuracy  of  the  observations. 
Loss  of  weight,  under  some  conditions,  may  be  much  more  rapid 
than  gain  ever  is.     The  latter  at  best  does  not  usualh7  proceed  at  a 
rate  of  more  than  four  or  five  pounds  in  a  week,  even  during  con- 
valescence from  such  an  illness  as  typhoid  fever;  but  in  diseases  like 
cholera,  for  example,  in  which  emaciation  is  extremely  rapid,  the  loss 


QUANTITY   OF   FOOD   REQUIRED  325 

of  weight  may  amount  to  two  or  three  pounds  a  day,  or  possibly 
more. 

In  some  diseases  a  fallacy  arises  in  comparing  food  consumption 
with  body  weight.  In  fevers  there  is  usually  loss  of  weight,  but  this 
is  not  always  the  case.  Sometimes  in  aseptic  fevers  the  weight  may 
remain  uniform;  and  in  phthisis  there  is  sometimes  uninterrupted 
gain  during  a  moderate  hectic.  Leyden  found  that  in  fever,  while 
the  proteids  of  the  body  are  diminishing,  there  may  be  more  water 
stored  in  the  tissues,  and  in  cases  of  anasarca  and  dropsical  ac- 
cumulations of  rapid  development  it  is  quite  possible  for  the  weight 
to  increase,  while  in  reality  the  body  is  rapidly  wasting  away,  and 
it  would  be  a  very  grave  mistake  to  deduce  any  conclusions  for 
feeding  the  patient  from  the  weight  alone.  Another  important  con- 
sideration is  the  rapidity  of  loss  of  waste  food  products  from  the 
body. 

The  normal  weight  of  feces  which  should  be  voided  each  day  is 
five  or  six  ounces  —  about  one-fourth  of  which  is  solid  matter,  the 
rest  water.  Many  persons  do  not  pass  over  half  this  quantity  for 
days  together,  and  thus  go  on  accumulating  waste  material,  which 
adds  to  their  weight.  The  same  disproportion  between  food  inges- 
tion  and  the  elimination  of  urea  and  different  salts  in  the  urine  may 
exist.  Moreover,  the  loss  of  weight  by  excessive  perspiration  may 
reach  a  pound  or  two  a  day.  Athletes  subjected  to  violent  physical 
strain  and  stokers  working  in  great  heat  —  sometimes  of  120°  F. 
—  may  lose  two  pounds  in  an  hour  in  this  manner.  The  night  sweats 
of  phthisis  cause  considerable  actual  loss  in  weight,  besides  the  ex- 
haustion which  they  occasion.  The  loss  of  weight  through  the  aque- 
ous vapor  and  carbon  dioxide  in  the  lungs  may  vary  somewhat, 
although  it  is  less  changeable  than  might  be  supposed. 

For  all  these  reasons  it  is  necessary  to  investigate  conditions  thor- 
oughly before  adopting  conclusions  from  the  scales  for  application 
in  ordering  more  or  less  food,  or  altering  its  character. 

The  weighing  of  infants  immediately  before  and  after  nursing  at 
the  breast  is  an  excellent  and  fairly  accurate  method  of  determining 
how  much  food  they  are  getting,  and  infants  whose  nutrition  gives 
any  cause  for  anxiety  should  frequently  be  weighed,  for  in  them,  for 
obvious  reasons,  the  record  of  slight  variations  in  weight  may  be 
much  more  accurately  utilized  in  regulating  feeding. 

Calculation  of  Rations 

It  is  ordinarily  impossible  or  impracticable  definitely  to  weigh 
the  food  for  individual  consumption,  but  where  large  numbers  of  men 


326 


FOOD  PREPARATION   AND  PRESERVATION 


are  being  fed  by  contract  in  institutions,  or  as  sailors  or  soldiers,  or 
on  exploring  expeditions,  it  becomes  necessary  to  estimate  the  quan- 
tity of  food  required  per  diem  to  maintain  optimum  health  and 
vigor.  To  facilitate  such  estimates,  tables  have  been  computed  based 
upon  the  nutrient  value  of  different  foods. 

In  the  preparation  of  food  to  be  eaten  it  is  customary  to  allow 
10  per  cent  of  waste  in  calculating  the  gross  quantity  for  dietaries 
of  institutions,  army  rations,  etc.  Mrs.  E.  H.  Eichards  found  that 
this  percentage  is  somewhat  too  low. 

In  computing  the  quantity  of  food  needed  for  daily  consumption 
its  composition  should  be  taken  into  account.  The  estimates  of  differ- 
ent authors  vary  somewhat  in  regard  to  the  necessary  quantity  of 
different  kinds  of  food  in  a  mixed  diet,  but  notwithstanding  this 
there  is  a  general  correspondence  between  them.  The  chief  dis- 
crepancy concerns  the  quantity  of  fat  to  be  eaten,  and  it  will  be 
noticed  in  the  following  tables  that,  as  a  rule,  when  the  fat  is  cut 
down  the  carbohydrate  estimate  is  correspondingly  increased. 


Standard  Daily  Diet  for  an  Adult  Male  at  Ordinary  Work. 
Computed  in   Grams. 


Mole- 
schott. 

Pettenkofer 
and  Voit. 

Ranke. 

Play- 
fair. 

Foster. 

Lan- 
dois. 

Dujardin- 
Beaumetz. 

Voit 

At- 
water. 

Protein     

130 

137 

100 

119 

133 

130 

124 

118 

125 

Fats     

84 

117 

100 

51 

95 

90 

55 

56 

125 

Carbohydrates 

404 

352 

240 

530 

422 

330 

430 

500 

450 

Salts 

30 

30 

25 

Total    water- 

free  food   . 

648 

636 

465 

700 

650 

540 

609 

674 

700 

The  amount  of  nutrient  material  required  per  diem  by  a  healthy 
adult  male  doing  moderate  manual  labor  is  represented  by  Billings 
as  follows : 


Lean  meat   20  ounces. 

Bread     22       " 

Potatoes    10       " 

Three  or  four  cups  of  coffee. 

According  to  Chambers,  the  average  adult  at  ordinary  labor  ob- 
tains enough  food  in  a  day  if  he  eats  one  pound  of  meat  and  two 
pounds  of  bread  or  its  equivalent,  provided  no  peculiarities  of  size, 
health,  or  climate  are  to  be  accounted  for. 


QUANTITY   OF   FOOD   REQUIRED 
Healthy  Adult  Man,  Abundant  Diet  and  Rest     (Bauer). 


327 


Taken  in. 

Consumed. 

Stored  up. 

137 

137 

Fat            "... 

117 

52 

65 

Carbohydrates  

352 

352 

An  Ideal  Ration  of  Solid  Food    (Mrs.  E.  H.  Richards) 


MATERIAL. 

AMOUNT. 

PROTEIN. 

FAT. 

CARBOHYDRATES. 

Calories. 

Grms. 

Oz. 

Grms. 

Oz. 

Grms. 

Oz. 

Grms. 

Oz. 

Bread   

453.6 
226.8 
226.8 
28.3 
113.4 
453.6 
28.3 
14.17 

16 
8 
8 
1 
4 
16 
1 
1 

31.75 
34.02 
12.52 
6.60 
3.63 
18.14 

1.12 
1.20 
0.44 
0.23 
0.13 
0.64 

2.26 
11.34 
2.04 
7.50 
4.42 
18.14 

0.08 
0.40 
0.07 
0.26 
0.16 
0.64 

257.28 

4.04 

1,206.82 
243.72 
70.01 
135.42 
75.55 
613.21 
112.17 
118.62 

Meat     

Oysters    

"9".  60 
4.88 
90.72 
27.36 

6.  '34 
0.17 
3.20 
0.96 

Breakfast  cocoa 
Milk   

Broth    

Sugar 

Butter 

0.14 

12  27 

Total    

... 

106.80 

.... 

57.97 

389.84 

2,574.60 

An  Ideal  Ration  of  Liquid  Food    (Mrs.  E.  H.  Richards). 


MATERIAL. 

Amount. 

Protein. 

Fat. 

Carbo- 
hydrates. 

Calories. 

Beef  broth  or  consomme   

1  pint. 

Grams. 

20.5 

Grams. 

0.5 

Grams. 

88.70 

To  which  has  been   added   one 
large   egg,   minus   shell    .... 
Dried  fruit  soup    

2  oz. 
1   quart. 

7.1 

6.8 

166  6 

91.67 
410  00 

Lemon  jelly    

i  pint. 

6  5 

12  5 

77  90 

Whole   milk    

1    quart. 

34  0 

36  0 

44  0 

651  00 

Rice  or  arrowroot   

3  oz     (  dry  )  . 

6  3 

0  3 

67  2 

304  11 

Grape  sugar,  or  some  one  of  the 
prepared  foods  (dry)    

2  ^ 

100  0 

4.20  oc 

Total                  

2.5  quarts  to 

7fi  Q 

jq  c 

ooq  7 

2fHO    00 

3.0    quarts  * 

*  According  to  how  the  rice  is  given. 
A  Common  Invalid  Ration  too  Low  in  Protein   (Mrs.  E.  H.   Richards). 


• 

Protein. 

Fat. 

Carbo- 
hydrates. 

Calories. 

1  pint  of  beef  broth  or  consomme     

Grams. 
20.5 

Grams. 

0.5 

Grams. 

88  7 

1  pint  of  dried  fruit  soup       

50 

205.0 

1  pint  of  lemon  whey   

21.5 

79 

521.7 

1  pint  of  Imperial  Granum,  containing  3  oz. 

6.8 

0.4 

64 

294.0 

2  Quarts  of  liquid      Total      

27.3 

22.4 

193 

1,109.4 

328  FOOD  PREPARATION  AND  PRESERVATION 

A  Ration  Rich  in  Protein  —  After  Acute  Disease  (Mrs.  E.  H.  Richards). 


MATERIAL. 

Amount. 

Protein. 

Fat. 

Carbo- 
hydrates. 

Calories. 

Bread          

Grms,      Oz. 

453  6      16 

Grams. 

31  75 

Grams. 
2  26 

Grams. 
257  28 

1  205  81 

Meat   

453  6      16 

64  04 

22.68 

487  62 

Milk  without  cream   .  '.  

453  6      16 

29  02 

18  00 

39  00 

444  48 

Coffee  or  tea  with  cream  

453  6      16 

4  60 

3  25 

V  14 

53  43 

Butter    

14  17      i 

0  14 

12  27 

118  62 

56  7        2 

54  72 

224  35 

129.55 

58.46 

352.14 

2,746.12 

Less  10  per  cent  for  indigesti- 
bility    

12.95 

5.84 

35.21 

274  61 

Total     

116.60 

52.62 

316.93 

2,534.31 

Table  Compiled  by  Mrs.  E.  H.  Richards  and  Miss  Marion  Talbot. 
One  day's  food,  at  the  University  of  Chicago,  calculated  to  determine  the 
amounts  and  proportions  of  the  various  constituents  and  their  comparison 
with  the  general  average. 


Pounds. 

Per 
cent 
protein. 

Per 

cent 
fat. 

Per 
cent 
car- 
bohy- 
drate. 

Pounds 
protein 
net. 

Pounds 
fat  net. 

Pounds 
carbo- 
hydrate 
net. 

Calo- 
ries. 

50.0 

Stew  and  cold  meat   .  . 

21.0 

8  0 

10.5 

4.0 

90.0 

White   potatoes    

1.8 

0  ?, 

19  1 

1.6 

0.18 

17.2 

45.0 

Sweet    potatoes    

1  5 

0  4 

?,6  0 

0.7 

0.2 

11  7 

4.0 

Dried  beef   

34.0 

7  5 

1.4 

0.3 

77.0 

Flour  and  grain  

11.5 

1  8 

70  0 

8.9 

1.4 

53.9 

3.0 

Tapioca    

1.3 

83  0 

2.5 

192.0 

Milk    

3.5 

3  7 

4  7 

6.8 

7.1 

9.0 

13.0 

Cream    

3.0 

1?,  0 

3  0 

0.4 

1.6 

0.4 

15.0 

Butter  

2.0 

83  0 

0  5 

0.3 

12.5 

15.0 

Sugar   

96  5 

14.5 

6.0 
9.0 

Prunes    
Oranges,     less     20     per 

3.5 
1.0 

65.0 
11  0 

0.2 

4.0 

0.8 



50.0 
7  2 

Bananas,    less    50    per 
cent   waste    
Eafsjs   . 

4.85 
12  5 

i^i'o 

19.7 

1.3 

0.9 

Q.S 

5.0 



41  0 

Lamb    

20.0 

15  0 

8.2 

6.2 

26  0 

Turkey   

19  0 

5  0 

5.0 

1.3 

14  0 

Steak    

15  0 

??,  0 

2.1 

3.1 

657  2 

48.3 

38.68 

119.0 

76.0 

(Less  turkey,  lamb,  and 
broad   left   over)       .  . 

• 

7.9 

2.06 

23.6 

£.81    9 

Divided  by   130 

40.4 

36.62 

95.4 

&  4 

Per  person  nutrients 

0.310 

0.281 

0.733 

Grams. 

126.5 

Grams. 
114.7 

Grams. 

332.0 

?,946 

Daily    average    for    the 
6    months,    nutrients 

108.0 

102.0 

381.0 

2,953 

329 


As  a  fair  average  for  computation  it  may  be  said  that  300  grains 
of  nitrogen  and  4,800  grains  of  carbon  are  daily  required. 

In  order  to  obtain  the  nitrogen  necessary  for  the  system  from  a 
diet  composed  exclusively  of  starchy  food  —  as,  for  example,  pota- 
toes—  it  would  be  necessary  to  eat  ten  pounds.  If  bread  alone  is 
eaten,  four  'pounds  would  be  required,  and  this  contains  more  than 
twice  the  carbon  needed.  About  fifteen  pounds  of  cabbage  would 
have  to  be  eaten  for  the  same  purpose.  On  the  other  hand,  to  ob- 
tain sufficient  carbon  from  an  exclusive  meat  diet  at  least  six  pounds 
of  beef  must  be  consumed.  If  eggs  were  used  exclusively,  about 
twenty-three  pounds  would  have  to  be  eaten.  An  ordinary  lump 


Years  of  age 

0       4       8121620342332 


40      44     48      52     56     60     64      68      72     "76     90 


FIG.  43. —  APPROXIMATE  QUANTITY,  IN  GRAMS,  OF  DIFFERENT  CLASSES  OF 
FOODS  CONSUMED  IN  TWENTY-FOUR  HOURS,  COMPUTED  ACCORDING  TO  AGE. 
(Mrs.  E.  H.  Richards.) 


of  sugar  is  the  food  equivalent  of  an  ounce  of  potato.  A  quart  of 
milk,  three-fourths  of  a  pound  of  beef,  and  five  ounces  of  bread  are 
all  approximately  equal  in  nutrient  value. 

The  following  table  from  Landois  and  Stirling  is  arranged  to 
show  the  total  quantity  of  each  single  food  which  it  would  be  neces- 
sary to  eat  in  order  to  obtain  the  requisite  protein  on  the  one  hand 
and  the  requisite  carbohydrate  on  the  other.  For  the  purpose  of 
comparison  these  authors  estimate  the  necessary  daily  amount  of 
carbohydrate  at  448  grams  and  the  protein  at  130  grams: 
24 


330 


FOOD   PREPARATION   AND   PRESERVATION 


Protein. 

Carbohydrate. 

Rice    

2,562  gra 
1,444 
491 
582 
968 
2,875 
388 
10,000 
614 

HIS. 

572  gra 
625 
806 
819 
902 
930 
2,011 
2,039 
2,261 

ms. 

Wheat  bread  

Lentils    

Peas    

E  eres    . 

Rye  bread   

Cheese    

Potatoes     

Beef    

[i.  e.  to  obtain  a  normal  day's  ration  of  protein  from  rice  alone,  one  must 
eat  2,562  grams,  but  to  obtain  a  normal  day's  ration  of  carbohydrates,  one 
need  only  eat  572  grams.] 

If  a  man  doing  hard  labor  were  to  attempt  to  live  upon  milk 
alone  he  would  require  fully  ten  pints  a  day  to  obtain  the  carbon 
necessary.  Either  of  these  quantities  of  single  foods  greatly  over- 
taxes the  digestive  system.  In  fact,  it  would  be  impossible  for  most 
persons  to  eat  meals  of  this  character.  The  food  would  be  too  heavy; 
it  would  take  too  long  to  consume  it,  and  it  would  become  too 
monotonous.  It  is  absolutely  essential,  therefore,  for  man  so  to 
regulate  the  composition  of  his  diet  as  to  balance  properly  its  neces- 
sary chemical  elements.  This  balance  is  best  secured  by  a  diet  in 
which  nitrogen  bears  the  relation  to  carbon  of  1  to  3.5  or  4.  In 
bread  the  proportion  of  carbon  to  nitrogen  is  3.0  to  1,  and  in  meat  it 
is  reversed,  and  stands  1  to  3.5.  Munk  and  Ufflemann  state  that 
the  ratio  between  animal  and  plant  albumin  in  the  diet  should  be 
3  to  7. 

It  is  also  more  economical  for  the  workingman  to  have  fats  and 
sugar  in  his  diet  and  not  to  live  exclusively  on  meat.  The  con- 
tractor soon  learns  that  ill-fed  men  do  poor  and  insufficient  work. 
The  force  must  be  developed  out  of  the  latent  energy  of  matter 
whether  bricks  are  to  be  carried  to  the  top  of  a  building  by  a  man 
or  a  hoisting  machine.  The  carbon  of  coal  is  oxidized  to  develop 
force  for  lifting  through  the  engine.  The  carbon  in  all  the  forms 
of  fats,  starches,  and  sugars  is  utilized  in  the  body  of  man  to  enable 
him  to  do  the  same  work.  The  laborer  does  right  therefore  when 
he  eats  bacon  with  his  cabbage  and  treacle  with  his  oatmeal.  There 
is  one  fallacy  in  the  above  comparison  that  should  not  be  overlooked, 
which  is  that  the  more  fuel  the  machine  consumes,  the  more  work 
it  does ;  this  applies  to  man  only  within  narrow  limits,  and  too  large 
a  quantity  of  food  promptly  brings  him  into  trouble  with  his  di- 
gestive organs.  (See  Overeating,  p.  411.) 

Water-free  Food. —  The  average  percentage  of  water  in  bread  is 


QUANTITY  OF  FOOD  REQUIRED  331 

37  per  cent;  in  cooked  meat,  54  per  cent;  in  vegetables,  7  per  cent 
or  more  (Letheby). 

"  Assuming  the  food  average  as  23  water-free  ounces  daily  and 
the  mean  body  weight  150  pounds,  the  body  receives  1-105  of  its 
own  weight  in  water-free  solids.  The  range  in  different  persons  is 
1-80  to  1-120  of  the  body  weight"  (Parkes). 

This  problem  may  be  differently  stated,  reckoning  in  the  water 
with  the  solid  food  as  follows: 

A  robust  man  weighing  144  pounds  may  consume  1-24  of  his  body 
weight,  or  6  pounds,  in  nourishment  per  diem,  divided  as  follows : 

Inorganic  food  —  i.  e.,  water  and  salts  —  3.5  pounds. 

Organic  food  (animal  food,  1  pound;  vegetable  food,  1.5  pound), 
2.5  pounds. 

It  is  usually  better,  unless  active  exercise  is  being  taken,  to  eat  a 
little  less  meat  and  more  vegetable  food  than  the  above  allowance, 
and  to  drink  a  little  more  fluid. 

The  average  quantity  of  dry  (i.  e.,  water-free)  food  by  weight  re- 
quired for  breakfast  may  be  put  at  8  ounces,  for  luncheon  6  ounces, 
for  dinner  9  ounces,  total  23  ounces.  The  "middle  diet"  at  Guy's 
Hospital,  which  is  supplied  to  the  majority  of  the  patients,  furnishes 
29.5  ounces  of  solid  food  per  diem  in  addition  to  liquids.  Of  course 
such  persons  are  taking  no  active  exercise.  This  is  equivalent  to 
17  ounces  of  dry  or  water-free  food.  It  consists  of  4  ounces  of 
meat  (cooked),  12  ounces  of  bread,  8  ounces  of  potatoes,  1 
ounce  of  butter,  0.75  ounces  of  sugar,  0.25  ounces  of  tea,  and  2.5 
ounces  of  milk. 

Chaumont  estimates  that  a  man  of  150  pounds  can  do  an  average 
day's  work  upon  a  diet  of  proteids,  4.5  ounces;  fats,  3.75  ounces; 
carbohydrates,  18  ounces,  and  salts,  1  1-12  ounce.  These  estimates 
are  of  water-free  constituents. 

Nitrogenous  material  should  constitute  "  one-fifth  of  the  water-free 
food,  or  from  4  to  5  ounces  for  active  life.  The  ordinary  meat  ration 
for  soldiers  is  12  ounces  per  diem,  of  which  20  per  cent,  or  2.4 
ounces,  is  deducted  for  waste  of  bone,  tendon,  etc.  For  inactive  life, 
from  3  to  3.5  ounces"  (Pavy).  This  diet  will  completely  replace 
the  nitrogen  eliminated  from  the  body.  "  Two  pounds  of  bread  and 
three-fourths  of  a  pound  of  uncooked  beef  contain  as  nearly  as  pos- 
sible the  right  proportion  of  carbon  and  nitrogen."  This  makes  44 
ounces  of  solid  food.  Water-free  meat  contains  about  0.20  per  cent 
nitrogen. 

Fat.  added  to  the  daily  diet  in  the  proportion  of  about  one  ounce 
of  butter  not  only  supplies  necessary  force  and  tissue  elements,  but 


FOOD   PREPARATION   AND   PRESERVATION 

acts  favorably  in  promoting  assimilation  of  other  classes  of  food 
and  diminishing  to  a  great  extent  the  wear  and  tear  of  the  tissues. 
With  active  work,  especially  in  a  cold  atmosphere,  more  than  double 
this  amount  is  consumed  with  advantage,  and  even  2.5  ounces  form 
an  average  allowance  for  many  classes  of  workmen. 

The  carbohydrates  are  required  in  quantities  between  14  and  22 
ounces,  their  main  use  being  to  convey  energy  for  heat  and  mechan- 
ical work. 

Salts. —  The  quantity  of  salts  required  for  daily  use  varies  from 
0.5  to  1  1-12  ounce.  This  quantity  is  less  affected  by  conditions  of 
temperature  and  exercise  than  are  other  food  constituents. 

Water. —  The  quantity  of  water  drunk  per  diem  is  usually  less  than 
should  be  taken.  Many  persons  believe  that  it  is  injurious  to  drink 
much  fluid  with  meals  and  forget  to  take  any  between,  and  as  a 
result  not  enough  water  is  consumed  to  dissolve  thoroughly  and 
eliminate  the  waste  matter  of  the  system.  The  average  quantity  of 
urine  voided  is  52  ounces,  10  ounces  more  are  lost  from  the  surface 
of  the  lungs,  and  18  ounces  from  the  skin.  This  total  of  80  ounces 
must  be  daily  replaced  to  maintain  the  equilibrium  of  the  body. 
The  solid  food  of  a  mixed  diet  has  been  shown  above  to  contain 
on  the  average  50  or  60  per  cent  of  water,  so  that  about  25  ounces 
of  water  are  taken  into  the  system  daily  as  an  integral  part  of  the 
food.  In  addition,  at  least  55  ounces  or  more  should  be  drunk  either 
as  plain  water  or  in  various  beverages. 

Another  way  of  stating  the  above  facts  is  that  the  average  quan- 
tity of  solid  food  (not  water-free)  which  is  required  by  adults  is 
between  40  and  45  ounces  per  diem,  and  the  total  amount  of  food, 
including  plain  water  and  all  other  fluids,  should  be  from  95  to  120 
ounces,  of  which  three-fifths  or  four-fifths  is  composed  of  water, 
and  the  remaining  one-  or  two-fifths  of  water-free  substance.  These 
estimates  are  only  intended  for  general  application,  and  there  are 
necessarily  many  exceptions. 

Muscular  exertion  demands  an  increase  in  both  solid  and  fluid 
food,  but  the  former  is  more  essential  than  the  latter,  if  the  exertion 
be  prolonged. 

It  is  estimated  that  in  each  twenty-four  hours  a  man  of  normal 
health  and  physique  absorbs,  including  the  respiratory  oxygen  and 
water,  about  7.25  pounds  of  material,  which  he  eliminates  in  a  corre- 
sponding quantity  of  waste,  about  three-fifths  of  which  is  water. 

When  a  man  does  increasing  work,  unless  his  food  be  proportion- 
ately increased,  he  begins  to  consume  his  own  tissues  until  their  loss 
so  weakens  liim  that  he  is  obliged  to  desist  from  a  part,  at  least,  of 


QUANTITY   OF  FOOD   REQUIRED  333 

his  labor.  Should  the  disproportion  between  output  and  income 
continue,  he  becomes  so  enfeebled  as  to  be  liable  to  the  inroads  of 
hardship  in  various  forms  —  especially  those  of  cold  and  zymotic 
diseases. 

One  of  the  best  means  of  determining  the  proper  amount  of  food 
to  sustain  a  man  in  good  health  is  derived  from  a  study  of  the  ex- 
periences of  arctic  explorers.  Their  men  are  subjected  to  great 
hardships  and  feats  of  endurance,  as  well  as  to  intense  cold.  From 
the  nature  of  the  expeditions  no  superfluous  food  can  be  carried,  and 
yet  the  chief  factor  in  success  is  the  maintenance  of  good  bodily 
vigor.  For  these  reasons  the  rations  for  arctic  travelers  have  been 
most  carefully  established,  and  a  brief  review  of  them  will  throw 
much  light  upon  this  interesting  subject. 

The  Peary  expedition  to  the  north  pole  in  1887  used  19  ounces 
of  solid  food  as  the  ration  for  the  sledging  expedition,  but  this  soon 
proved  to  be  inadequate  in  the  cold  of  the  arctic  regions.  Dr.  Ray 
used  29  ounces,  which  also  proved  insufficient,  and  later  34  ounces 
of  solid  food.  Various  other  expeditions  have  used  32  ounces  of 
solid  food,  consisting  wholly  of  pemmican,  which  has  been  sufficient. 

Molintock,  another  arctic  sledge  traveler,  used  40  to  48  ounces 
of  food  daily.  Captain  Neary's  expedition  used  38  ounces  of  solid 
food,  proportioned  as  follows:  Meat,  20  ounces;  biscuits,  14  ounces; 
potatoes,  2  ounces;  sugar,  2  ounces.  To  this  were  added  chocolate, 
1  ounce;  rum,  2  ounces;  and  1.5  ounce  each  of  tea  and  tobacco  with 
condiments,  making  in  all  44  ounces  of  supplies. 

De  Long  quotes  from  the  physician  to  his  arctic  expedition  that 
"alcohol  proves  a  great  advantage,  keeps  off  the  craving  for  food, 
preventing  gnawing  at  the  stomach,  and  has  kept  up  the  strength 
of  the  men  as  given  —  3  ounces  per  day."  (This  was  during  starva- 
tion, but  as  stated  on  p.  269,  alcohol  is  injurious  to  the  prolonged 
maintenance  or  robust  health  in  cold  climates.) 

While  performing  active  service  in  the  cold  a  diet  of  1.5  pound 
of  stewed  deer's  meat  did  not  prevent  hunger,  but  1.5  pound  of 
pemmican  per  diem,  with  one-half  ounce  of  tea  and  one-half  ounce 
of  Liebig's  extract  of  meat,  supported  life  for  some  time.  On  leav- 
ing the  ship  and  starting  on  their  long  sledge  expedition,  the  follow- 
ing daily  ration  was  allowed  each  man  by  Lieutenant  De  Long: 

BREAKFAST 

Pemmican  4  ounces. 

Ham  1  ounce. 

Bread 3  "  pieces." 

Coffee    2  ounces. 

Sugar %  ounce. 


334  FOOD  PREPARATION  AND  PRESERVATION 

DlNNEB 

Pemmican    8  ounces. 

Liebig's  extract  1  ounce. 

Tea     1/2 

Sugar     %       " 

SUPPER 

Pemmican    4  ounces. 

Tongue    1  ounce. 

Tea    1/2       " 

Sugar    % 

Lime    juice    1 

Bread    4  ounces. 

While  held  fast  in  the  ice,  and  still  on  the  steamer,  the  average 
allowance  of  food  per  day  was  about  four  pounds,  but  some  com- 
plained of  being  hungry  on  this  ration. 

In  the  voyage  of  the  Jeannette  to  the  arctic  zone  in  the  polar 
expedition  of  1879-'81  a  very  liberal  diet  was  allowed  the  sailors  on 
entering  the  arctic  regions,  the  average  quantity  of  food  allotted  per 
man  per  diem  being  a  ration  of  5.5  pounds.  Meat  was  furnished 
three  times  a  day.  Fat  was  supplied  in  the  form  of  pork  and  butter, 
and  bread  and  potatoes  made  the  bulk  of  the  starchy  diet,  consti- 
tuting about  two-thirds  of  the  whole  amount  of  food.  The  diet  at 
first  included  large  quantities  of  condensed  milk,  butter,  eggs,  oat- 
meal, cheese,  and  macaroni,  together  with  a  great  variety  of  canned 
fruits  and  vegetables  and  dried  fruits,  such  as  apples,  peaches,  dates, 
figs,  prunes,  and  raisins. 

In  Lieutenant  A.  W.  Greely's  account  of  the  expedition  (Three 
Years  of  Arctic  Service)  he  says:  "The  amount  of  food  per  man 
each  day  actually  eaten  in  over  two  years  at  Fort  Conger  was  as 
follows. : 

Meat     26.8  ounces. 

Canned    vegetables    10.0 

Sugar  and  sirup   • 5.3 

Farinaceous    articles     13.6 

Canned  fruits  4.7 

Dried  fruits,  preserves,  fruit,  butter,  and  pickles  ...  2.9 

"  This  aggregate  of  64.3  ounces  would  doubtless  be  increased  by 
coffee,  chocolate,  tea,  spices,  condiments,  etc.,  to  nearly  seventy 
ounces.  This  amount  may  reasonably  be  assumed  as  the  quantity 
of  food  necessary  for  the  maintenance  of  a  man's  health  in  a  lati- 
tude such  as  Conger  (81°  44'  N".),  where  the  actual  temperature  is 
4°  F."  He  adds  that  tomatoes  proved  to  be  the  most  serviceable 
vegetable,  and  apples  and  peaches  the  best  fruits.  The  beverages 
consisted  of  coffee,  tea,  chocolate,  cider,  and  a  small  quantity  of 


QUANTITY   OF  FOOD   REQUIRED  335 

rum,  the  latter  averaging  two  gills  weekly  for  each  man,  which  he 
regarded  as  beneficial  from  the  effect  it  had  upon  the  cheerfulness 
and  good  humor  of  the  men.  Meat  in  the  above  table  included  fat, 
in  the  shape  of  pemmican  (four  ounces),  butter,  lard,  pork,  and 
bacon. 

The  hours  for  meals  were  as  follows :  Breakfast,  7  A.  M.  Dinner, 
4  P.  M.,  and  two  lunches.  The  latter  consisted  of  hard  bread  and 
butter,  tea  and  coffee.  The  typical  menu  was  as  follows: 

Breakfast. —  Corn  beef,  oatmeal,  fresh  bread,  chocolate,  or  coffee. 

Dinner. —  Vegetable  soup,  baked  pork  and  beans,  corn  bread, 
stewed  peaches,  and  coffee. 

On  sledging  expeditions  it  was  important  to  reduce  the  weight 
and  bulk  of  the  food  to  a  minimum;  accordingly  in  the  Greely  ex- 
pedition of  1882  the  daily  allowance  for  sledging  expeditions  was 
39  ounces,  to  which  was  added  an  ounce  of  lime  juice.  The 
lime  juice  was  carried  solidified  in  the  form  of  small  squares,  in 
which  form  it  proved  refreshing  and  invigorating  to  the  exhausted 
men.  This  constituted  the  ration  of  the  first  year,  1882.  Greely 
writes : 

"  On  the  above  ration  of  1882  parties  kept  the  field  for  forty 
days  in  a  mean  temperature  below  zero  17.8°  C.,  and  returned  in 
health  and  strength." 

In  1883  the  experience  of  the  previous  year  led  him  to  modify 
the  ration  by  replacing  part  of  the  bread  with  butter  and  meat.  This 
modified  ration  consisted  of  — 

Meat    22  ounces. 

Butter     2 

Vegetables    4       " 

Bread 10       " 

Sugar    2       " 

Milk    y2  ounce. 

Tea  or  chocolate    1       " 

Salt    % 

Pepper     & 

therefore  the  ration  contained  40.5  ounces.  Greely  says  again: 
"  Three-fourths  of  the  ration  were  about  equal  quantities  of  pem- 
mican, bacon,  and  frozen  musk-ox  meat,  while  the  balance  was  made 
up  of  canned  sausages  and  corned  beef  in  about  equal  quantities  " 
(Three  Years  of  Arctic  Service).  He  suggests  as  a  still  further  im- 
provement that  the  vegetable  ration  should  consist  of  3  ounces 
of  preserved  potatoes,  the  remaining  ounce  being  replaced  by  half 
an  ounce  each  of  milk  and  extract  of  beef  tea,  which  is  the  best  drink 
for  the  arctic  regions.  It  should  be  used  chiefly  in  the  field  in 


336 


FOOD   PREPARATION   AND   PRESERVATION 


the  form  of  an  extract.  A  little  coffee  is  preferable  to  chocolate. 
The  latter  was  found  to  induce  thirst  during  the  day.  Tea  should 
be  compressed  or  used  as  an  extract.  Curry  paste  and  other  power- 
ful condiments  were  also  found  serviceable.  Alcohol  was  not  con- 
sidered necessary  as  a  food. 

During  the  third  winter  of  his  arctic  expedition,  from  November 
1,  1883,  to  June  23,  1884,  Greely's  per  capita  ration  for  his  entire 
party  was: 


Meat     4.0    ounces. 

Beef  extract   0.26  ounce. 

Evaporated    potato    ....   0.4 

Soup      0.6 

Tomatoes      0.3 

Peas    0.2 

Corn    0.2 

Carrots     0.1 

Bread    6.0     ounces. 

Dog  biscuit   0.8     ounce. 


Butter    0.5     ounce. 

Lard    0.26 

Rice     0.1 

Raisins     0.16 

Tea,  compressed   0.3 

Extract  of  coffee    0.44 

Extract   of  chocolate    .  .  0.3 

Milk     0.2 

Mulberries  .  0.2 


It  is  noticeable  that  alcohol  is  omitted  from  this  ration.  C.  E. 
Borchgrevink  (First  on  the  Antarctic  Continent,  1898-1900)  made 
extensive  use  of  dried  vegetables,  and  such  articles  as  ham,  bacon, 
curry  and  rice,  cheese,  dried  fish,  sardines,  jam,  marmalade,  and 
cocoa. 

Among  the  advocates  of  restricted  eating,  especially  of  proteid 
food,  is  Prof.  Eussell  H.  Chittenden,  of  the  Yale  Scientific  School, 
who  in  his  work  "  Physiological  Economy  in  Nutrition,"  details  the 
dietetic  experiments  made  upon  a  number  of  students,  professional 
men  (including  himself)  and  a  selected  group  of  13  members  of 
the  U.  S.  Army  Hospital  Corps  in  1903.  The  subjects  of  the  ex- 
periments took  daily  gymnasium  and  other  exercise  and  careful 
records  of  their  strength  and  weight  were  compared  with  the  intake 
of  food  and  excretion  of  waste.  Prof.  Chittenden  defines  "  phys- 
iological economy  in  nutrition  "  as  meaning  "  temperance,  not  pro- 
hibition." Neither  is  it  strict  vegetarianism,  but  implies  a  reduc- 
tion of  proteid  food  to  55  grams  per  diem,  which  is  not  quite 
one-half  that  ordinarily  consumed  by  the  average  man,  which,  ac- 
cording to  accepted  standards,  is  125  grams  per  diem  for  a  work- 
ing man.  The  total  food  consumption  is  also  much  reduced.  It  is 
claimed  that  for  a  healthy  man  of  140  Ibs.  210  calories  of  protein 
per  diem  is  ample  in  a  diet  of  2,800  calories,  as  against  the  usual 
512  protein  calories  in  a  diet  of  3,500.  Or  stated  otherwise,  the  usual 
estimate  for  protein  ingestion  for  a  normal  man  is  2.4  to  2.7  calories 
of  protein  energy  per  pound  of  body  weight  per  diem,  but  Chitten- 
den's  diet  allows  only  1.3  to  1.7  calories. 


QUANTITY   OF   FOOD   REQUIRED 

Chittenden's  sample  dietary  is  as  follows: 


337 


BREAKFAST. 


Proteid, 
Grams. 


Calories. 


One  shredded  wheat  biscuit    3 . 15 

One  teacup  of  cream    3.12 

One  German  water  roll 5.07 

Two  one-inch  cube  of  butter 0.38 

Three-fourth  cup  of  coffee   0.26 

One-fourth  teacup  of  cream    0.78 

One  lump  of  sugar    

12.76 
LUNCH. 

One  teacup  homemade  chicken  soup   5.25 

One  Parker  House  roll    3.38 

Two  one-inch  cubes  of  butter   0.38 

One  slice  lean  bacon 2.14 

One  small   baked   potato    1 .53 

One   rice   croquette    3.42 

Two  ounces  maple  syrup    

One  cup  of  tea  with  one  slice  lemon  

One  lump  of  sugar    

16.10 
DINNER. 

One  teacup  cream  of  corn  soup   3 . 25 

One  Parker  House  roll 3.38 

One-inch  cube  of  butter 0.19 

One  small  lamb  chop,  broiled   8.51 

One  teacup  of  mashed  potato   3.34 

.Apple-celery-lettuce  salad  with  mayonnaise  dressing  0.62 

One  Boston  cracker,  split 1 .32 

One-half-inch  cube  American  cheese   3.25 

One-half  teacup  of  bread  pudding   5.25 

One  demi-tasse  coffee  

One  lump  of  sugar   

29.21 


106 
206 
165 

284 


38 


850. 

60 

110 

284 

65 

55 

150 

166 

'38 


928 

72 

110 

142 

92 

175 

75 

47 

50 

150 

'38 


951 


This  system  results,  it  is  stated,  in  greater  simplicity  and  economy 
in  diet;  lessened  burden  is  placed  upon  the  digestive  and  excretory 
functions;  lessened  liability  to  fatigue,  and  actual  improvement  in 
physical  and  mental  standards  results.  The  leucomaines  resulting 
from  katabolic  transformation  of  proteid  material  within  the  body 
may,  under  some  conditions,  produce  toxic  effects,  and  their  trans- 
formation and  elimination  may  overtax  the  liver  and  kidneys,  pos- 
sibly laying  the  foundation  of  disease  processes.  Prof.  Chittenden 
does  not  profess  to  establish  dogmatic  numerical  standards  and  ad- 
mits that  under  varying  conditions  of  labor  or  strain,  larger  quan- 
tities of  proteid  and  other  foods  may  be  required  temporarily.  He 
claims  that  young,  vigorous  athletes  can  maintain  their  physical  and 
mental  vigor  upon  a  daily  output  of  only  8.8  grams  of  nitrogen  (as 


338  FOOD   PREPARATION   AND  PRESERVATION 

against  the  customary  16  or  18  grams),  representing  a  metabolism 
of  55  grams  of  protein. 

Prof.  Chittenden's  views  have  excited  considerable  controversy,  not 
from  their  novelty,  for  there  have  been  many  previous  disciples  of 
extreme  temperance  in  eating,  but  because  of  the  number  of  per- 
sons simultaneously  experimented  upon,  and  the  details  of  the  nitro- 
gen determinations.  They  do  not  concern  any  special  restriction  in 
quality  but  rather  quantity  of  food.  As  he  himself  admits,  they 
are  in  opposition  to  the  almost  universal  standards  recommended  by 
physiological  chemists,  as  for  instance,  the  elaborate  researches  made 
at  the  Agricultural  Experiment  stations  throughout  this  country  upon 
much  larger  groups  of  persons  of  varied  occupations,  ages  and  races. 
(See  pp.  17,  18,  326-328.) 

For  example,  Benedict  and  Milner  of  the  Wesleyan  Station  state 
that: 

"  As  a  matter  of  fact,  all  evidence  thus  far  accumulated  goes  to 
show  that  large  quantities  of  food  accompanied  by  increased  mus- 
cular activity  result  almost  invariably  in  the  same  proportional 
digestibility  of  the  nutrients  of  the  food  as  under  ordinary  con- 
ditions." 

Sir  James  Crichton-Brown  writes: 

"  All  the  successful  races  have  habitually  consumed  proteid  far 
in  excess  of  the  Chittenden  standard  and  far  in  excess  of  what 
was  required  for  tissue  repair,  and  when  we  find  a  definite  relation 
between  proteid  consumption  and  racial  success  there  is  good  ground 
for  believing  that  behind  it  there  is  biological  law." 

The  fundamental  questions  involved  are  two:  first,  does  the  con- 
sumption of  a  reasonable  excess  of  food  beyond  the  lowest  nitroge- 
nous equilibrium  compatible  with  normal  weight,  strength  and  health, 
really  overtax  the  chemical  organs  of  the  body,  or  pave  the  way 
to  functional  or  organic  disease?  Second:  does  such  low  equilibrium 
better  fit  the  body  to  cope  with  the  manifold  mental  or  physical 
emergencies  which  arise  in  daily  life,  in  those  who  are  not,  for  the 
time  being,  under  the  placid  influence  of  a  daily  monotonous  routine 
of  "training." 

The  answer  to  the  first  question  involves  many  complex  theories 
of  the  origin  of  certain  diseases,  which  cannot  definitely  be  decided 
in  the  state  of  present  knowledge.  Proteid  overeating  certainly  does 
not  uniformly  produce  any  one  disease  or  group  of  diseases,  and  many 
races  or  tribes  of  man  live  in  health  and  vigor  upon  predominant 
proteid  diet  (vide  Diet  of  the  Eskimos,  etc.,  pp.  359).  Conversely, 
however,  it  is  equally  true  that  many  persons,  and  many  existing 


QUANTITY  OF  FOOD  REQUIRED 


339 


diseases  are  benefited  by  temporary  or  permanent  protein  restriction. 

The  answer  to  the  second  question  is  not  solved  by  the  experi- 
ments under  discussion,  which  do  not  include  endurance  tests,  or 
the  effect  of  strain,  or  the  result  in  after  life  of  a  comparatively 
short  course  of  special  diet  undergone  by  a  group  of  selected  men 
in  previous  health,  most  of  them  at  a  period  of  life  which  admits 
of  great  variation  in  diet  of  any  sort,  without  marked  immediate 
disturbance  one  way  or  the  other. 

Temperance  in  eating,  as  in  drinking,  in  exercising  or  working, 
should  unquestionably  be  the  aim  of  a  well-regulated  life,  but  the 
advocacy  of  a  wholesale  permanent  reduction  of  the  total  proteid 
food  of  man  to  less  than  one-half  of  what  heredity,  habit  or  circum- 
stance has  inured  him  to,  admits  of  so  many  exceptions  as  to  appear 
unnecessarily  extreme.  As  an  illustration  of  how  far  authorities 
disagree,  F.  W.  Pavy  of  London,  the  well-known  author  of  works 
on  dietetics  has  said: 

"Undoubtedly,  millions  of  human  beings  are  to-day  committing 
slow  suicide  by  a  too  excessive  ingestion  of  the  carbohydrates." 

E.  Maurel  of  Toulouse  inclines  towards  a  moderate  proteid  re- 
striction in  the  diet  for  those  in  normal  health.  His  standard  given 

MAXJBEL'S  STANDARD  DIET. 


Total 
Grams. 

Pro- 
tein. 

Fat. 

Carbo- 
hydrate. 

Calories. 

Total 
Calories. 

/.  Breakfast 

50 

4.g 

25. 

120  1 

Coffee               

10 

2.5 

10 

Milk  

100 

3.5 

4 

5.5 

75   [ 

245 

Sugar  

10 

10. 

40  J 

II.  Breakfast   or   luncheon 
Bread                        .        .... 

150 

12. 

75 

360  1 

Wine                  

250 

140 

EOTOTS    or     . 

2 

15. 

11 

180 

Fish  or    

100 

18. 

10 

180 

Meat    

100 

18. 

15 

250  [ 

995 

Fresh  Vegetables         .... 

100 

3. 

10 

10 

145 

Cheese    

30 

9. 

5 

90 

Fresh    fruit    

100 

5 

60  J 

Dinner 
Bread   

150 

12 

75 

360  "1 

Wine    

250 

140  I 

Soup   Bread   or   vermicelli 
or  vegetables  

200 

6. 

5 

25 

175  1 

Chicken  or  meat   

100 

18. 

10 

5 

200  f 

1,205 

Fresh  vegetables    

100 

3 

15 

10 

190 

Cheese    

30 

9. 

5 

90 

Fresh  fruit  .  .    .  .          .... 

100 

12 

50 

96.5 

66 

2,445 

340  FOOD  PREPARATION  AND  PRESERVATION 

in  his  "Traite  de  1'Alimentation  et  de  la  Nutrition"  (1908),  is 
subjoined  for  the  3  meals  of  the  day.  As  general  rules  he 
recommends  eating  not  more  than  two  dishes  and  two  desserts  at 
luncheon  and  dinner,  one  dish  consisting  of  animal  and  one  of  vege- 
table food,  besides  not  more  than  150  grams  of  bread  (nearly  5  ozs.) 
and  250  c.  c.  (9  ozs.)  of  wine.  Hors-d'oauvres  are  omitted. 

Forced  and  Reduction  Feeding 

By  forced  feeding  or  "  suralimentation "  is  meant  the  giving  of 
a  highly  nutritious  diet,  chiefly  of  animal  food,  at  frequent  inter- 
vals in  the  maximum  quantity  which  a  patient  can  digest.  Its  chief 
benefit  is  in  the  treatment  of  tuberculosis,  and  the  method  is  fully 
discussed  under  that  heading  (see  Tuberculosis).  It  is  also  useful  in 
chronic  syphilis,  with  inanition  in  diabetes,  mellitus  and  insipidus, 
neurasthenia,  melancholia,  hysteria  and  exophthalmic  goitre. 

By  reduction  feeding  is  meant  a  diet  especially  designed  in  quality 
as  well  as  quantity  to  reduce  weight.  Its  essential  value  is  in  the 
treatment  of  obesity,  under  which  heading  the  method  is  fully  dis- 
cussed elsewhere.  It  is  also  beneficial  in  selected  cases  of  gout, 
chronic  heart  disease,  arteriosclerosis,  asthma,  cirrhosis  and  chronic 
nephritis,  especially  with  anasarca. 

Quantity  of  Food  Eaten  Per  Annum 

The  usual  estimate  for  the  total  quantity  of  all  food  material,  in- 
cluding solids,  water,  and  respiratory  oxygen  as  well,  which  is  con- 
sumed by  a  healthy  adult  male  per  annum  is  one  and  a  half  ton. 

Following  is  the  estimate  of  total  food  supply  for  eighteen  months 
for  one  man  in  the  Yukon  region.  The  total  weight,  about  one 
ton,  is  considerably  less  than  that  of  food  ordinarily  eaten,  because 
fruit  and  vegetables  must  be  carried  in  an  evaporated  condition. 

"  The  chief  items  are  600  pounds  of  flour,  300  pounds  of  bacon, 
150  pounds  each  of  beans  and  sugar,  75  pounds  each  of  rolled  oats 
or  other  mush  material  and  cornmeal,  50  pounds  of  rice,  six  dozen 
cans  of  condensed  milk,  35  pounds  of  butter  in  sealed  cans,  150 
pounds  of  evaporated  vegetables,  100  pounds  of  evaporated  fruit, 
50  pounds  of  primes  and  raisins,  30  pounds  of  dried  fish,  40  pounds 
of  coffee,  with  baking  powder,  soda,  salt,  pepper,  ginger,  mustard, 
yeast  cakes,  tea,  lime  juice  (very  important),  dried  beef,  extract 
of  beef,  soups  in  tins,  sausage,  etc.,  as  desired,  bearing  in  mind  al- 
ways that  variety  of  food  promotes  health.  There  has  been  more 
or  less  said  in  the  newspapers  about  various  concentrated  foods,  but, 


QUANTITY   OF  FOOD   REQUIRED  341 

with  the  exception  of  evaporated  vegetables  and  fruit,  condensed 
preserves,  condensed  milk,  and  beef  extract,  nothing  yet  has  been 
brought  forward  which  has  been  proved  desirable.  One  cannot  afford 
to  experiment  with  his  stomach  in  Alaska." 

Men  eat  about  two-thirds  of  all  the  meat,  and  women  one-third. 
Men  consume  about  four-fifths  of  all  the  alcoholic  beverages,  and 
women  one-fifth.  The  latter  consume  much  more  tea  than  men. 

Soyer  has  computed  tables  of  the  total  quantity  of  foods  con- 
sumed by  a  man  during  his  lifetime.  He  estimates  that  a  man  dur- 
ing sixty  years  of  life  after  early  childhood  eats  33%  tons  of  meat, 
vegetables,  and  farinaceous  food,  and  that  an  ordinary  man  by  the 
time  he  has  attained  to  seventy  years  has  consumed  30  oxen,  200  sheep, 
100  calves,  200  lambs,  50  pigs,  1,200  fowls,  300  turkeys,  24,000  eggs, 
4.5  tons  of  bread,  and  3,000  gallons  of  tea  and  coffee. 

Measurement  of  Food 

For  most  patients  the  weighing  of  food  at  meals  is  inconvenient  or 
impracticable.  It  is,  however,  desirable  to  have  some  rough  method 
of  measuring  foods  so  that  the  quantities  eaten  may  be  compared 
with  published  food  analyses  and  their  energy  computed.  Foods  like 
lumps  of  sugar,  crackers,  etc.,  exist  in  fairly  uniform  portions,  and 
others  may  be  measured  by  the  tablespoonful,  teaspoonful  or  teacup- 
ful.  A  pound  is  the  equivalent  of  453.5  grams  and  an  ounce  of  28.3 
grams  avoirdupois.  (A  five  cent  piece  (nickle)  weighs  5  grams.)  A 
tablespoon  holds  15  c.  c.,  a  teaspoon  5  c.  c.,  a  common  tumbler  or 
coffee  cup  holds  200  c.  c.  The  following  estimates  are  given  by  A. 
L.  Benedict  of  Buffalo. 

Grains. 

Lump  of  sugar  6. 

Soda  crackers 25. 

Shredded  wheat  biscuit 30. 

Hard  roll 60. 

Lamb  chop   (meat)    30. 

Thin  slice  roast  beef  25. 

Small  potato 50. 

Slice  of  bread  3  ins.  scj 25. 

A  "  portion  "  or  "  helping  "  of  butter 15. 

"  Portion  "  of  ice  cream  125  c  c. 

Tea,  coffee  and  cocoa  may  be  estimated  by  the  amount  of  sugar 
and  milk  or  cream  added. 

"When  it  is  necessary  to  keep  close  account  of  the  nutrition  of  a 
patient,  it  is  well  to  reserve  for  him  a  loaf  of  bread,  a  special  sugar 
bowl,  a  package  of  cereal,  etc.,  and  to  obtain  the  amount  used  in  a 
certain  period  by  subtraction." 

Dudley  Roberts  gives  the  following  convenient  summary  of 


342 


FOOD   PREPARATION   AND   PRESERVATION 


D 

DO 

d^                              a               fa       .               « 

d 

"3 
§ 

a 

3 

c 

1 

a 

i 

i 

i 

3 

a 

[ 

a 

"Npo 

—  ol 

.i 

0 

a 

d 

§•0 

d 

n 

^ 

=• 

I 

8 

I 

S 

s 

o 

E 

ll 

^^ 

~ 

a 

's 

•O 

a 

1 

I 

'.marks. 

depends  on 

»•§ 

/    u 

1 

• 
1 

due  to  larg« 

d  peas  to  a 

h 

CD 

3 

"o 

n  the  sugar 

e 

• 

*S 

IS 

P  g 

— 

3 

C 

>» 

"S  ®i 

•c 

^; 

in 

f 

•_, 

tc 

a 

"*a 

XM-»* 

S 

c 

B 
O 

a 

'C 

fl 

9 

•a-5 

§-: 

-Is 

1 

a 

£ 

1 

•3 

1 

1 

! 

3 

111 

°|i            2|      1  I 

rfel 

o 
•a 
e 

-  — 

I 

0 

| 

0 

K 

* 

^ 

g 

d 

d 

11 

^•CDO^ 

^  r  -"<-.'•- 

OOO 

C  ?? 

oo  ooo 

—  —  r  i  — 

COP4GO 

NOCCM 

<c 

• 

3* 

M 

J 

"C 
o 

i 

IS8SSS8    jpj    ^^      srssg  p*  ,  SS8|  S8S| 

e 

3 

"33J3^ 

"2  "a  a  e 

"3 

—  -  ~ 

2            3 
g       2  2*a 

"3  "3 

^3      S 

"a 

"33^ 

"3 
tfl 

Household  Meas 

p 

_  V 

Us 

•    MM« 

a  heaping  teaspoi 
a  heaping  teaspo 
a  heaping  te«spo 
a  heaping  teaspo 

a  teacupful 
a  teaspoonf  u 
a  heaping  teaspoi 
a  soup-platef) 

a  heaping  teaspoi 
one 
one 
Ik  one-inch  cu 
a  one-inch  cul 
heaping  tablespoc 

MM          O 

—5 

'a'a 
d  d 

MA 

I 

heaping  teaspoo 
one 
one 
heaping  tablespoi 

heaping  tablespo 

heaping  tablespoi 
heaping  tablespd 
one  (3  inches  Ic 
a  teacupful 

one 
one  medium  s 
one  medium  K 
medium  size  sau< 

J 

3  3 

ooti 

1111 

s  =  =  s     a 

O  COHO           C) 

IN  H  a  a  a  a  a 
o  o  attx     MM  5 

||===|B 

SSES 
BBBB 

S 

111 

S  =  =  = 

•-  •_  -I  '_ 

00  30  3C 

-£     • 

an  clear 

OOCOOO            1-1 

i-li-lOO      OOO 
rtus       f-l^lu5 

a 

- 

II 

S£S 

sgss 

AS  EATEN. 

1  skimmed  n 

k,  sweetened 
k,  unsweeten 

ders  

3 
- 

z 
"I 

•SB  • 

i'l 

jniny 

:  :  :  :  a 

i 

v 

jiii 
!|li 

||| 

Nil 

•o      :  :  :       -« 

d  :  :  gn 

9 

_£ 

S:     a 
•a   ° 

°3T3 

I 

FOODS 

x 

=1! 

Ssv 

Condensed  mi 
Condensed  mil 
Cocoa  powders 
Chocolate  pow 

t«  = 

g«g 

a'S  so        -j 

§'?j:^    | 

X££^      i 

&HSH         < 

a      • 
«     .  :  :      ja 

~     •£•      « 
>,     :  J?      "* 

•S  iSxSSBwS 

SSOOBOO 

Cereals,  eaten 
Shredded  whe 
Triscuit  
Peas,  fresh  or 

Peas,  dried.... 

Beans,  dried.. 
Beans,  fresh  o 
Potatoes  —  med 
Jelly,  sweetenc 

Apples  
Oranges  
Bananas  
Dried  fruit,  pi 

QUANTITY  OF  FOOD   REQUIRED  343 

Starvation  and  Inanition 

Starvation,  or  asitia,  is  a  term  which  technically  applies  to  the 
lack  of  sufficient  food  for  the  maintenance  of  the  body,  while  inanition 
means  the  lack  of  assimilation  of  food  by  the  tissues.  Where  there 
is  defective  absorption,  food  may  be  ingested  in  abundant  quantity, 
but  inanition  results  from  lack  of  ability  to  absorb  it  and  develop 
force  and  nutriment  from  it.  The  interval  through  which  man 
can  subsist  without  food  depends  upon:  1,  External  conditions  of 
temperature  and  moisture;  2,  the  amount  of  work  being  performed; 
and  3,  the  condition  of  the  body. 

1.  The   maintenance   of   a   uniform   warm   external    temperature 
prolongs  the  period  through  which  man  can  endure  abstinence  from 
food.     Exposure  to  cold  accelerates  starvation  symptoms  by  reducing 
the  vitality  of  the  body  and  the  resistance  of  the  system.     Moisture 
in  the  air,  by  preventing  evaporation  from  the  surface  of  the  body, 
prolongs  the  period  of  starvation  which  can  be  endured. 

2.  Persons   who    refrain   completely    from   exercise  .can   live    far 
longer  without  food  than  when  undergoing  active  work.     Self-for- 
getfulness  in  times  of  famine,  by  diverting  the  mind  from  the  suf- 
ferings of  the  body,  tends  to  prolong  life. 

3.  Well-nourished  persons  can  endure  longer  intervals   of   absti- 
nence from  food  than  the  weak  or  diseased.     The  distress  of  delirious 
or  apparently  insensible  persons  may  be  augmented  by  lack  of  suffi- 
cient food.     Sex  has  no  influence  with  the  effects  of  starvation,  but 
they  are  most  keenly  felt  at  the  extremes  of  age,  by  young  children, 
and  senile  subjects. 

Those  who  have  much  fat  stored  in  their  tissues  call  upon  this 
supply  to  maintain  the  .energy  of  the  body  in  the  absence  of  food, 
and,  having  a  larger  supply  than  thin  or  emaciated  persons,  they  can 
endure  starvation  much  longer,  although  they  may  complain  more 
bitterly  of  the  pangs  of  hunger  than  invalids,  who  are  accustomed 
to  a  low  diet.  Chossat's  experiments  with  starving  animals  proved 
that  while  they  lost  40  per  cent  of  body  weight,  the  loss  of  fat  alone 
reached  90  per  cent,  being  greatly  in  excess  of  that  of  any  other 
substance. 

When  food  is  completely  withheld,  life  cannot  be  prolonged  beyond 
six  to  ten  days  in  the  majority  of  instances.  During  the  winter  of 
1876-'77  an  accident  occurred  in  a  colliery  in  South  Wales  by  which 
four  men  and  a  boy  became  imprisoned  for  ten  days  without  food. 
At  the  expiration  of  this  period  they  were  found  alive,  and,  although 
very  feeble,  they  were  able  to  walk  when  released.  They  had  had 


344  FOOD  PREPARATION   AND  PRESERVATION 

a  supply  of  water,  and  the  atmosphere  in  which  they  were  confined 
was  moist.  At  another  colliery  accident  in  Wales  a  number  of  men 
were  confined  in  a  mine  for  six  days  without  food,  and,  although 
their  sufferings  were  extreme,  nearly  all  were  able  to  walk  out  on 
being  rescued.  As  a  result  of  an  earthquake  in  Calabria,  Sicily, 
in  1783,  several  persons  were  imprisoned  in  falling  ruins.  A  girl 
of  eleven  years  survived,  having  been  six  days  without  food,  and 
another  girl  of  sixteen  years  survived  eleven  days  of  starvation. 

The  lack  of  food  may  be  endured  with  far  less  torture  if  water  be 
applied  in  abundance  to  the  system.  When  water  is  withheld  in 
addition  the  body  loses  weight  much  more  rapidly,  the  tissues  become 
dry,  the  thirst  excessive,  the  secretions  are  suppressed,  and  the  suf- 
fering is  greatly  intensified. 

Voluntary  Fasting 

Of  late  years  several  persons  have  attempted  prolonged  feats  of 
starvation,  tempted  by  love  of  notoriety  or  desire  of  gain,  by  ex- 
hibiting themselves  for  the  gratification  of  public  curiosity.  In  sev- 
eral instances  they  have  been  carefully  watched,  by  medical  experts 
and  there  is  every  reason  to  believe  that  the  fast  has  been  conducted 
with  honesty.  In  at  least  two  of  these  authenticated  instances,  those 
of  Tanner  and  Succi,  the  complete  starvation  period  has  been  pro- 
longed for  over  forty  days.  In  both  cases  fluids  were  allowed,  and 
one  of  the  men  relieved  intense  epigastric  pain  and  food  craving  by 
condensed  medication. 

Succi  was  an  Italian  who,  in  1890,  undertook  an  absolute  fast  of 
forty-five  days,  during  which  period  he  lost  42%  pounds  and  drank 
1,154  ounces  of  water,  or  an  average  of  about  25%  ounces  per  diem. 
This  he  took  in  the  form  of  plain  water, '  mineral  water,  and  ice. 
He  became  alarmingly  emaciated  during  the  fast,  but  even  on  the 
last  day  had  strength  to  walk  about  the  room.  He  resumed  eating 
by  first  taking  cocoa,  and  subsequently  bouillon  and  other  light  ar- 
ticles, and  made  a  complete  recovery.  His  mind  remained  clear 
throughout.  He  took  occasional  doses  of  a  few  drops  of  an  elixir 
supposed  to  contain  opium. 

There  have  been  a  number  of  cases  from  time  to  time  recorded 
of  "  fasting  girls."  They  are  usually  of  nervous  hysterical  tempera- 
ment. On  reaching  the  age  of  puberty  they  become  dyspeptic  and 
grow  shy  and  disinclined  to  eat  what  is  good  for  them,  although 
they  may  gratify  abnormal  food  cravings  surreptitiously..  They  are 
very  likely  to  be  impressed  strongly  at  the  same  time  by  religious 
beliefs,  and  in  their  disordered  mental  condition  to  acquire  the  de- 


QUANTITY   OF  FOOD   REQUIRED  345 

lusion  that  it  is  sinful  to  eat.  This  delusion  becomes  fixed,  and 
they  then  are  regarded  as  "  freaks "  and  achieve  much  newspaper 
advertising.  They  should  be  treated  as  ordinary  cases  of  hysteria 
simply,  and  be  removed  from  over-sympathetic  friends  and  dealt  with 
kindly  but  firmly.  Hydrotherapy  yields  excellent  results,  and  a 
good  spanking  may  not  be  amiss  in  awaking  the  patient  to  a  realiz- 
ing sense  of  her  errors.  The  claim  sometimes  made  in  such  cases  as 
those  just  described,  that  they  lose  no  weight,  is  nonsensical,  for 
the  body  must  diminish  in  weight  continually  by  evaporation  of 
water  from  the  lungs  and  skin  and  its  passage  from  the  kidneys  and 
by  the  exhalation  of  carbon.  Edward  Smith  estimates  that  the  quan- 
tity of  carbon  exhaled  in  one  day  of  fasting  is  equivalent  to  that 
contained  in  twenty  ounces  of  bread. 

When  either  voluntary  or  forced  starvation  takes  place  very  grad- 
ually, especially  in  elderly  people,  their  systems  become  slowly  ac- 
customed to  very  small  quantities  of  food. 

Luigi  Cornaro  was  a  Venetian  gentleman  who  advocated  a  very 
abstemious  diet,  and  whose  own  case  is  often  cited  in  illustration  of 
the  smallest  quantity  of  food  which  may  support  life.  He  was  born 
in  1463;  after  a  reckless  and  intemperate  youth  he  reformed,  and 
by  careful  dieting  prolonged  his  life  to  one  hundred  and  three  years. 
He  published  a  Treatise  on  a  Temperate  Life,  and  for  the  last 
forty-eight  years  of  his  own  existence  he  claimed  to  have  subsisted 
on  a  daily  allowance  of  twelve  ounces  of  vegetable  food  with  fourteen 
ounces  of  light  wine.  He  occasionally  ate  eggs,  but  rarely  took  any 
other  form  of  animal  food. 

There  is  much  general  wisdom  in  some  of  his  doctrines,  but,  un- 
fortunately, no  one  else  who  has  attempted  to  practice  his  rules  has 
met  with  similar  success  in  prolonging  life.  The  majority  of  man- 
kind would  undoubtedly  prefer  to  live  fewer  years  for  the  pleasure  of 
being  less  abstemious. 

Periods  of  voluntary  fasting  of  greater  or  less  duration  are  rec- 
ommended and  practiced  by  devotees  of  many  religious  sects.  Such 
fasting  was  formerly  carried  to  a  greater  extent  by  ascetics  than  at 
the  present  time.  As  a  means  of  mental  discipline  or  cultivation  of 
will  power,  fasting  may  in  some  instances  be  defended,  but  fasting 
"to  be  useful  must  be  voluntary"  (Chambers),  otherwise  it  is  prone 
to  cause  irritability  of  temper,  and  it  may  even  lead  to  deception  to 
obtain  food.  Such  fasting  may  be  carried  to  an  excessive  and  in- 
jurious degree  unless  it  be  limited  definitely  and  supervised.  It  is 
more  powerful  in  its  effect,  moreover,  if  it  only  seldom  be  undertaken. 
If  a  man  so  reduces  himself  by  fasting  that  he  cannot  use  his  in- 


346  FOOD   PREPARATION   AND  PRESERVATION 

tellectual  faculties  with  accustomed  vigor  he  may  be  sure  that  he 
is  doing  himself  injury.  Better  than  complete  fasting  for  purposes 
of  mental  discipline  or  religious  motives  is  the  temporary  elimination 
from  the  diet  of  accustomed  luxuries,  or  giving  up  such  articles  of 
daily  use  as  butter,  sugar,  salt,  wine,  tobacco,  etc.  This,  in  fact,  is 
a  custom  practiced  by  many  persons  during  the  Lenten  season. 

The  day  has  long  since  passed  when  fasting  can  be  regarded  as 
favoring  either  clearness  of  intellect,  muscular  strength,  or  endur- 
ance, and,  as  Gerland  has  said,  "the  ethnologist  can  trace  the 
physical  and  mental  decay  of  whole  nations  to  a  long  course  of  in- 
sufficient food."  Dr.  Denis,  of  Brussels  University,  presented  an 
interesting  report  at  the  International  Congress  of  Anthropology  for 
1892,  showing  striking  parallelism  in  the  curves  of  famine  and 
crime,  and  of  marriages  as  inversely  related  to  the  price  of  wheat. 

Symptoms. —  The  symptoms  which  result  from  complete  starva- 
tion are  characteristic.  If  food  be  withheld  suddenly,  the  sensation 
of  hunger  gradually  increases  at  first,  becomes  extreme,  lasts  for  two 
or  three  days,  and  slowly  disappears.  It  is  accompanied  by  a  gnaw- 
ing pain  in  the  epigastrium,  which  is  relieved  on  pressure.  The  pain 
may  disappear  with  the  hunger,  but  it  is  followed  by  a  sensation  of 
extreme  weakness  or  faintness,  which  is  both  local  in  the  stomach 
and  general  throughout  the  body.  The  sensation  of  thirst,  on  the 
contrary,  when  all  fluid  is  withheld,  persists  until  death  or  until  the 
subject  becomes  insane  or  unconscious. 

When  food  is  gradually  withheld,  urgent  hunger  may  not  be  felt 
at  all,  but  the  longer  and  more  severe  the  fast,  the  more  difficult 
does  digestion  become.  The  circulation  grows  feeble,  the  heart  ac- 
tion rapid,  the  respiration  shallow  and  possibly  slow  and  irregular. 
There  is  apt  to  be  some  thirst,  even  though  water  be  supplied.  If 
it  be  withheld,  the  torture  becomes  unbearable.  Constipation  may 
be  succeeded  by  diarrhoea,  but  it  more  often  remains.  The  facies 
are  typical,  the  expression  is  anxious  and  staring,  the  orbital  fat 
disappears,  and  the  eyes  are  sunken  and  glassy.  Corneal  ulceration 
may  be  present.  General  bodily  emaciation  ensues,  the  muscles  are 
soft  and  reduced  in  size  by  more  than  one-half,  and  the  abdominal 
viscera  to  a  similar  degree,  the  skin  becomes  pale,  loose,  and,  from 
change  in  the  secretion  of  perspiration,  emits  a  peculiar  fetor  and 
acquires  a  clay-like  color.  The  feet  and  ankles  may  swell,  owing 
to  the  enfeebled  circulation. 

The  victims  become  so  ravenous  that  all  sense  of  taste  gives  place 
to  the  intense  hunger  and  such  substances  as  leather  may  be  devoured 
to  produce  a  sensation  of  satiety.  Upon  one  of  the  ill-fated  arctic 


QUANTITY  OF  FOOD  REQUIEED  347 

expeditions,  on  one  occasion,  the  tea  accidentally  being  omitted  from 
the  kettle,  dirty  water  was  drunk  by  the  starving  men  without 
recognizing  the  difference.  The  secretions  are  altered,  and  become 
inactive.  The  urea  excretion  falls  to  one-fourth  the  normal.  The 
total  volume  of  blood  is  diminished,  and  anaemia  is  extreme. 

•  The  body  temperature  begins  to  fall  in  the  first  day  of  the  period 
of  starvation,  and  continues  falling,  so  that  a  loss  of  ten  or  more 
degrees  below  the  normal  of  98.6°  F.  may  occur. 

In  extreme  cases  muscular  action  is  no  longer  possible;  there 
are  vertigo  and  faintness  on  raising  the  head,  the  voice  is  lost,  and 
gradually  the  nervous  system  succumbs  to  languor  and  general 
prostration;  the  mind  becomes  more  and  more  dull,  listless,  and 
even  idiotic,  the  victim  being  unable  to  describe  his  condition  or 
express  his  wants.  He  may  have  hallucinations,  insomnia,  and 
dreams,  in  which  are  often  pictured  scenes  of  plenty. 

The  sufferings  produced  by  slow  starvation  distract  the  mind  and 
render  connected  thought  difficult.  If  long  continued,  the  mind  be- 
comes unbalanced,  and  men  who  have  been  shipwrecked  and  left  to 
wander  in  the  open  sea  in  rowboats  for  a  long  time  without  food 
usually  become  delirious,  or  even  maniacal,  within  four  or  five  days, 
in  which  latter  state  they  have  been  known  to  devour  human  flesh. 

In  1874  three  men  and  two  boys  were  castaway  for  twenty-two 
days  in  an  open  boat.  They  had  at  first  ten  days'  provisions,  and 
subsequently  nothing  but  old  boots  and  jellyfish,  and  they  fought 
violently  with  each  other  in  the  delirium  which  ensued. 

During  prolonged  starvation  the  most  important  organs  of  the 
body  are  nourished  at  the  expense  of  others,  especially  of  the  skeletal 
muscles.  For  example,  in  an  animal  starved  for  thirteen  consecutive 
days  it  was  found  that  whereas  the  muscles  lost  30  per  cent  in  weight, 
the  brain  lost  but  3  per  cent  and  the  heart  2.5  per  cent. 

The  ultimate  effects  of  starvation  are  identical  whether  the  proc- 
ess be  gradual  or  rapid,  occupying  days  or  years,  and  death  results 
when  the  body  has  lost  six-tenths  of  its  weight.  It  may  occur  while 
the  victim  is  in  stupor  or  coma  from  cardiac  failure  or,  possibly,  in 
convulsion.  The  actual  cause  of  death  has  by  many  been  attributed 
to  the  loss  of  body  heat.  While  this  is  undoubtedly  a  contributing 
factor,  it  is  more  reasonable  to  suppose  that  it  is  due  to  the  general 
inanition  of  the  muscles  and  nerves  and  the  progressive  enfeeble- 
ment  of  the  heart  action.  The  heart  muscle  not  infrequently  will 
be  found  to  have  undergone  fatty  degeneration.  It  is.  however,  true 
that  in  animals  kept  warm  by  artificial  means  the  advent  of  death 
from  starvation  may  be  considerably  postponed. 


348  FOOD  PREPARATION  AND  PRESERVATION 

While  undergoing  starvation  the  blood  is  reduced  in  volume  pro- 
portionately with  the  loss  in  body  weight,  but  it  nevertheless  main- 
tains the  balance  of  its  normal  average  composition  (Panum  and 
Voit). 

Hunger  is  not  always  a  reliable  guide  as  to  the  need  of  the  sys- 
tem for  food.  Some  dyspeptics  are  always  hungry  and  eat  more  than 
they  can  digest.  Hunger  begets  a  habit  of  too  rapid  eating,  and 
more  food  may  be  taken  than  is  necessary,  because  it  has  not  had 
time  to  be  absorbed  and  reach  the  tissues  before  the  meal  is  over. 
Moreover,  hunger  temporarily  may  be  appeased  by  eating  other  sub- 
stances than  food,  like  bits  of  old  leather,  for  example,  which  appear 
to  act  mechanically  in  the  stomach.  For  this  purpose  men  rendered 
insane  by  hunger  will  sometimes  swallow  all  manner  of  useless  and 
harmful  substances,  such  as  buttons,  pieces  of  metal,  pebbles,  etc. 

No  more  graphic  and  pathetic  account  of  the  miseries  of  starva- 
tion exists  than  is  found  in  the  journal  of  Lieutenant  De  Long,  com- 
manding the  expedition  of  the  Jeannette,  which  visited  the  arctic 
regions  in  1879-'81  (The  Voyage  of  the  Jeannette,  Journals  of  George 
"W.  De  Long,  1883).  After  leaving  their  sinking  vessel  the  mem- 
bers of  the  expedition  were  exposed,  at  first  in  open  boats,  and 
later  in  their  long  sledge  journey,  to  the  most  exhausting  work  and 
to  intense  suffering  from  cold  and  wet.  They  frequently  dragged 
their  sleds  in  severe  storms  for  ten  or  twelve  miles  a  day,  while 
subsisting  solely  upon  half  a  pound  of  stewed  deer  meat,  with  a 
little  tea  three  times  a  day.  This  food  being  exhausted,  they  were 
obliged  to  consume  the  meat  of  their  last  remaining  dog,  which  they 
ate  fried.  They  subsisted  upon  this  food  exclusively  for  four  days 
longer,  having  an  allowance  of  but  half  a  pound  a  day,  and  finally 
their  last  journey  of  twenty-five  miles  was  performed  with  no  other 
nourishment  than  a  few  ounces  of.  alcohol  and  an  infusion  made 
from  some  old  tea  leaves.  During  this  time  their  intense  suffering 
from  hunger  was  partially  alleviated  by  chewing  scraps  of  deer  skin, 
which,  from  its  bulk  in  the  stomach,  seemed  to  afford  slight  relief. 

The  alcohol  being  exhausted,  they  lived  for  another  day  upon 
a  teaspoonful  of  olive  oil,  with  a  breakfast  composed  of  an  infusion 
made  from  the  arctic  willow  (containing  really  no  nourishment) 
and  "  two  old  boots."  After  this  the  men,  becoming  weaker  and 
weaker,  were  unable  to  proceed  farther  on  their  journey,  being 
driven  back  by  intense  cold  and  the  difficulty  of  crossing  the  par- 
tially unfrozen  rivers.  Their  feebleness  gradually  overcame  them, 
until  one  by  one  they  died  of  inanition.  Four  men  survived  for 
sixteen  days  upon  absolutely  no  food  whatever,  and  possibly  their 


QUANTITY   OF  FOOD  REQUIRED  349 

sufferings  were  even  further  prolonged,  but  the  journal  of  their  gal- 
lant and  heroic  commander  ceased  at  this  point,  for  he,  too,  died. 

In  the  starvation  which  overtook  the  members  of  the  Greely  party 
on  the  Lady  Franklin  Bay  Expedition,  and  caused  the  death  of  a 
large  number  of  the  company,  attempts  were  made,  as  in  the  case  of 
the  Jeannette  expedition,  to  relieve  the  agonies  of  hunger  by  filling 
the  stomach  with  indigestible  material  of  various  kinds.  The  skin 
sleeping  bags  were  roasted  or  boiled  and  eaten,  and  even  oil-tanned 
skin  was  consumed,  while  the  sufferings  of  the  men  were  intensified 
by  the  presence  of  the  game  in  sight  but  out  of  reach.  A  few 
shrimp  and  lichens  were  obtained  and  stewed  with  seal  skin. 

During  the  siege  of  Paris  in  1871,  when  thousands  of  the  inhabit- 
ants were  reduced  to  starvation,  it  was  found  that  a  diet  which  was 
barely  sufficient  to  support  life  consisted  of  ten  ounces  of  bread  with 
one  ounce  of  meat. 

In  prisons  the  diet  limit  has  often  been  reduced  too  low.  If 
barely  sufficient  to  maintain  life,  and  hard  labor  be  imposed,  weak- 
ness, sickness,  and  death  will  inevitably  follow.  In  an  overcrowded 
prison  a  daily  ration  of  twenty-eight  ounces  of  unbolted  meal  and 
five  ounces  of  bacon  has  been  known  to  cause  death  by  slow  star- 
vation. As  a  means  of  discipline  a  starvation  diet  is  sometimes  en- 
forced in  penal  institutions  for  a  few  days,  and  it  is  usually  quite  as 
efficacious  as  corporal  punishment.  A  diet  which  is  designed  to 
effect  its  aim  by  monotony  as  well  as  reduction  in  quantity,  but  with- 
out reaching  the  limit  of  cruelty,  is  the  following,  which  has  been 
used  at  the  United  States  military  prison  at  Fort  Leavenworth : 

Breakfast. —  Hash  or  stew,  8  ounces ;  bread,  7.5  ounces. 

Dinner. —  Soup,  8  ounces ;  bread,  7.5  ounces. 

After  twenty  continuous  days  of  this  diet  eight  ounces  of  bread 
are  allowed  for  supper.  This  diet  has  been  found  to  make  the  most 
refractory  men  soon  manageable.  (See  Diet  in  Prisons.) 

Treatment. —  The  treatment  of  persons  rescued  from  starvation 
should  be  conducted  with  the  utmost  care.  The  digestive  system  is 
so  enfeebled  that  to  allow  them  to  yield  to  the  cravings  of  returning 
appetite  is  to  insure  immediate  death  by  overburdening  the  stomach 
and  circulation.  The  body  should  be  kept  warm  and  in  absolute 
rest,  and  warm  fluid  nourishment  in  minute  quantities  —  half  tea- 
spoonful  doses  of  beef  peptones,  meat  juice,  or  egg  albumin,  may 
be  given  at  intervals  of  fifteen  minutes  or  half  an  hour.  If  no 
vomiting  or  evil  symptom  results,  small  quantities  of  peptonized  milk 
may  be  tried  at  half-hour  intervals.  Alcoholic  stimulants  in  large 
quantity  are  to  be  avoided,  but  a  few  drops  of  brandy  or  whisky  may 


350  FOOD   PREPARATION   AND  PRESERVATION 

be  given  from  time  to  time  in  water.  If  the  stomach  be  irritable, 
nutrient  enemata  should  be  employed.  The  following  day  the  quan- 
tity of  food  may  be  increased  slightly,  but  if  emaciation  is  extreme 
and  enfeeblement  is  pronounced,  the  patient  should  be  kept  upon  a 
fluid  diet  for  ten  days  or  more.  Easily  digested  forms  of  starchy 
food  then  may  be  added,  such  as  bread,  arrowroot,  gruel,  cocoa, 
boiled  rice,  and  the  like. 

Famine 

"When  starvation  occurs  upon  a  large  scale,  affecting  a  community 
with  famine,  pestilence  is  sure  to  accompany  it.  Disease  has  al- 
ways been  rampant  in  Ireland  when  the  potato  crops  have  failed, 
and  in  India  when  the  grain  supply  has  given  out.  Much  of  the  ill- 
ness which  occurred  in  the  early  history  of  the  Crimea  was  due  to 
insufficient  food,  and  in  the  Middle  Ages  the  ravages  of  pestilential 
diseases,  such  as  typhus,  smallpox,  the  plague,  etc.,  were  always 
worst  in  times  of  general  starvation.  The  history  of  epochs  of 
famine  in  siege  or  otherwise  is  always  accompanied  by  outbreaks 
of  violence,  for  hunger  begets  ill-temper,  vice,  and  crime.  This  has 
occurred  of  late  years,  notably  in  Athens,  Florence,  and  London, 
and  in  Paris  during  the  Commune. 

Physicians  and  nurses  in  charge  of  contagious  cases  are  particu- 
larly cautioned  to  eat  well  and  not  expose  themselves  to  infection 
while  suffering  from  fatigue  and  lack  of  food. 

Improperly  Balanced  Diet 

Improper  diet  is  often  quite  as  injurious  as  slow  starvation,  for  a 
person  who  eats  a  large  bulk  of  food  of  one  class,  to  the  exclusion 
of  other  classes,  may  delude  himself  by  thinking  that  he  is  taking 
nourishment  enough  on  account  of  the  degree  of  satiety  which  he 
derives  from  his  diet.  "  The  outward  appearance  of  such  persons  is 
to  a  certain  extent  characteristic,  marked  generally  by  a  pale  and 
puffy  aspect,  due  partly  to  a  general  excess  of  water  in  the  tissues 
and  partly  to  abnormal  deposition  of  fat"  (Bauer).  The  evil 
result  of  such  diet  is  very  apparent  among  infants  and  growing 
children  who  have  been  fed  upon  a  large  bulk  of  farinaceous  food  to 
the  exclusion  of  milk,  meat  juice,  etc.,  and  in  them  the  foundation 
may  be  laid  for  the  development  of  scurvy,  rachitis,  or  tuberculo- 
sis, and  sometimes  also  the  stomach  and  bowels  become  permanently 
distended.  (See  Diet  for  Infants  and  Children.) 

The  effect?  above  described  are  commonly  produced  by  excessive 
ingestion  of  starchy  and  saccharine  foods  to  the  exclusion  of  pro- 


QUANTITY   OF  FOOD   EEQUIRED  351 

tein,  and,  on  account  of  the  cheaper  cost,  the  children  of  the  poor 
are  more  likely  to  be  injured  in  this  manner  than  the  rich,  among 
whom  the  opposite  diet  —  an  excess  of  proteids  —  is  more  common. 
The  latter  sometimes  gives  rise  to  circulatory  disturbances,  over- 
works the  kidneys,  and  produces  nervous  irritability. 


PART  IV. 

SPECIAL  CONDITIONS  INFLUENCING  FOODS 
Age  and  Food  —  Diet  and  Heredity  —  Diet  and  Race. 

AGE  AND  FOOD 

Food  in  Childhood 

A  CHILD  at  three  or  four  years  of  age  consumes  nearly  one-fourth 
as  much  food  as  it  requires  at  adult  life,  for  during  this  process 
tissue  growth  is  very  rapid,  and  if  the  child  be  in  health,  the  bodily 
activity  is  relatively  very  great.  An  active  child  at  twelve  or  fifteen 
years  of  age  who  is  growing  fast  and  who  is  freely  exercising  may 
require  and  assimilate  as  much  food  as  a  man  past  middle  age,  and 
insufficient  food  and  food  of  defective  quality  and  composition  work 
proportionately  far  more  harm  during  the  growing  age. 

Inquiries  made  in  this  country  in  regard  to  the  diet  of  older  chil- 
dren and  young  adults  demonstrate  that  it  contains  a  proportionately 
large  quantity  of  fatty  food  —  much  more  than  is  customarily  con- 
sumed in  European  countries.  This  is  in  great  part  owing  to  the 
habit  of  eating  considerable  butter,  which,  generally  speaking,  the 
better  circumstances  of  Americans  enable  them  to  obtain. 

The  following  table  from  the  investigations  of  the  Munich  School 
gives : 

The  Minimum  Amount  of  Food  Necessary  for  Different  Ages 


AGE. 

Protein. 

Fats. 

Carbohydrates. 

Infant  until  one  and  a  half  year  
Child  from  six  to  fifteen  years         .... 

Grants. 

20-36 
70-80 

Grams. 
30-45 
37-50 

Grams. 

60-90 
250-400 

Man   (  moderate  work  )    

118 

56 

500 

Woman   

92 

44 

400 

Aged  man      

100 

68 

350 

Aged  woman   

80 

50 

260 

The   special   diet   regulations   for   infancy   and  childhood   are   de- 
scribed at  length  under  the  headings  Diet  in  Infancy  and  Diet  in 

Childhood,  p.  352. 

352 


AGE   AND  FOOD  353 

Food  in  Adult  Life 

The  full  adult  weight  is  not  usually  attained  before  the  twenty- 
fifth  year,  although  in  some  cases  it  is  reached  earlier.  In  many 
instances  adults  after  the  age  of  forty  or  forty-five  years  increase 
considerably  in  weight.  In  men  the  bones  continue  to  solidify  until 
about  the  thirtieth  year;  in  women  this  condition  is  reached  a  few 
years  earlier.  When  the  growth  of  the  body  and  development  of 
the  vital  organs  is  completed  the  use  of  food  consists  simply 
in  maintaining  the  equilibrium  of  the  tissues  by  replacing  waste 
with  new  material  and  in  furnishing  fuel  for  the  development  of 
force.  Many  persons  eat  more  than  is  required  for  these  purposes. 

It  is  often  difficult  for  a  man  between  the  ages  of  twenty  and 
thirty  years  who  has  led  an  exceptionally  active  and  vigorous  or 
perhaps  an  athletic  life  to  realize,  as  he  grows  older  and  passes 
on  towards  forty-five  or  fifty  years  of  age,  that  he  requires  less  food 
to  maintain  equilibrium  than  formerly,  and  his  habits  of  eating  ac- 
quired at  a  more  impressionable  period  of  life  cling  with  great 
pertinacity.  It  may  prove  an  advantage  sometimes  in  such  cases  to 
lessen  the  appetite  for  dinner  by  postponing  the  luncheon  hour,  or 
to  try  other  simple  means  of  restriction. 

These  observations  fail  of  application  to  the  poor,  whose  means 
do  not  allow  them  to  gratify  their  appetites,  and  in  the  case  of  those 
whose  diet  is  established  for  them.  There  is  quite  as  much,  if  not 
more,  ill  arising  from  deficient  feeding  as  from  overfeeding;  in  either 
case  the  difficulty  is  only  made  serious  by  long  continuance,  and 
occasional  great  indulgent  in  overeating  as  in  overdrinking  is  less 
productive  of  harm  than  habitual  indiscretions  of  a  lesser  degree.  So 
much  is  due  to  habit  in  the  different  organs  of  the  body  in  rela- 
tion to  food  that  the  stomach  and  intestine  will  usually  reject  undi- 
gested the  contents  of  an  occasional  excessive  meal,  whereas  with 
habitual  overeating  they  become  accustomed  to  appropriating  large 
quantities  of  food,  which  are  absorbed,  but  not  eliminated  without 
straining  the  excretory  organs,  or  which  may  be  stored  in  the  body 
in  the  form  of  incompletely  oxidized  material.  The  latter  accumulates 
until  the  system  rebels  and  a  violent  bilious  attack  by  vomiting  and 
purging  relieves  the  overburdened  organs.  There  are  persons  who 
have  so  little  restraint  over  their  appetites  that  they  persistently  in- 
dulge themselves  in  this  manner. 

Food  in  Old  Age 

In  old  age  there  are  inevitable  changes  which  slowly  arise  in  the 
circulatory  and  digestive  organs  of  the  body.     Although  the  general 
25 


354  SPECIAL  CONDITIONS  INFLUENCING  FOODS 

health  may  be  unimpaired,  the  circulation  is  less  vigorous,  and  the 
nervous  system  less  responsive  to  external  stimulation.  There  are 
degenerations  in  the  secreting  organs  with  a  tendency  to  deposition 
in  the  tissues  of  phosphate  and  carbonate  of  lime,  derived  from  the 
food.  Absorption  is  less  active,  and  there  is  diminished  adaptability 
of  the  whole  system  to  alterations  in  environment,  and  less  ability 
to  meet  the  requirements  of  emergencies,  such  as  sudden  calls  for  the 
use  of  muscles  or  mental  strain.  The  muscular  tone  of  the  in- 
testine is  apt  to  deteriorate  and  produce  constipation  and  a  relaxed 
condition  resulting  in  dilatation.  The  circulation  through  the 
mesenteric  vessels  and  those  of  the  portal  system  becomes  inactive, 
with  a  consequent  reduction  in  the  rate  of  absorption,  and  a  dimin- 
ished and  altered  secretion  in  the  liver  and  pancreas. 

For  these  reasons  the  digestive  powers  are  less  vigorous,  but,  on 
the  other  hand,  there  is  not  so  much  demand  for  fuel  in  the  body 
as  in  earlier  years.  The  vital  processes  conducted  by  the  circulation, 
respiration,  and  metabolic  changes  in  the  tissues  being  less  active, 
there  is  a  correspondingly  restricted  expenditure  of  energy. 

Persons  of  very  advanced  age  —  those  who  are  past  eighty  years 
or  more  —  sometimes  may  live  comfortably  on  an  astonishingly  small 
quantity  of  food.  J.  Forster  examined  the  food  of  the  inmates  of  an 
institution  for  elderly  widows  and  found  that  many  of  the  old  women 
subsisted  very  comfortably  upon  a  diet  containing,  in  grams,  albumin, 
67;  fat,  38;  and  carbohydrates,  266. 

Much  depends,  however,  upon  the  rapidity  with  which  the  changes 
above  described  have  developed,  and  dietetic  rules  for  such  cases  are 
not  to  be  based  upon  a  definite  period  of  years  so  much  as  upon 
the  degree  of  senility  present  in  individual  cases. 

Sir  Henry  Thompson  (Diet  in  Eelation  to  Age  and  Activity), 
in  commenting  upon  the  progressive  diminution  with  advancing 
years  of  physical  energy  and  of  the  power  to  eliminate  waste  material 
from  the  body,  and  the  consequent  harm  of  overeating,  says  that  if  a 
man  past  his  half  century  of  life  "continues  to  consume  the  same 
abundant  breakfasts,  substantial  lunches,  and  heavy  dinners  which  at 
the  summit  of  his  power  he  could  dispose  of  almost  with  impunity, 
he  will  in  time  either  certainly  accumulate  fat  or  become  acquainted 
with  gout  or  rheumatism,  or  show  signs  of  unhealthy  deposit  of  some 
kind  in  some  part  of  the  body  —  processes  which  must  inevitably 
empoison,  undermine,  or  shorten  his  remaining  term  of  life." 

In  the  dietetic  treatment  of  cases  of  extreme  old  age  the  rules 
which  are  naturally  suggested  are: 

1.  To   diminish   the   total   quantity   of  food   ingested. 


AGE  AND  FOOD  355 

2.  To  prescribe  food  at  frequent  intervals  in  small  quantity. 

3.  To  prescribe  only  easily  digestible  food,  which  does  not  produce 
too  large  a  residue  of  waste  matter,  either  in  the  intestinal  canal  or 
in  the  form  of  excrementitious  material  in  the  blood. 

The  idea  is  prevalent  that  the  quantity  of  food  and  stimulants 
should  be  increased  pari  passu  with  age,  but  this  is  as  wrong  in 
theory  as  it  is  pernicious  in  practice,  and  the  simple  fact  that  an 
article  of  particularly  rich  or  hearty  food  has  been  enjoyed  with 
impunity  for  many  years  is  no  argument  that  it  may  be  taken  in- 
definitely in  the  same  degree. 

In  commenting  upon  Professor  Humphrey's  report  upon  cente- 
narians, made  for  the  British  Medical  Association,  Dr.  Yeo  observes : 
"  Their  habits  in  eating  and  drinking  tended,  as  a  rule,  to  great  mod- 
eration in  both.  ...  Of  animal  food  the  majority  took  but  little. 
.  .  .  The  exact  quantity  is  mentioned  in  nine  instances:  One 
took  12  ounces,  one  6,  one  5,  and  six  4  ounces  daily.  In  the  use  of 
alcoholic  drinks  we  also  find  evidence  of  great  moderation." 

Some  more  recent  investigations  of  the  dietetic  habits  of  men 
over  one  hundred  years  of  age  show  considerable  diversity;  thus,  for 
example,  some  were  found  who  ate  only  one  meal  a  day,  while  others 
ate  four  or  five;  some  drank  little  fluid,  others  took  a  great 
deal;  some  were  total  abstainers  from  alcohol,  and  others  were  not. 

Persons  who  attain  to  very  advanced  age  are  almost  invariably 
of  lean  physique,  and  the  universal  testimony  in  regard  to  cente- 
narians is  that  they  have  never  abused  food  or  drink,  and  that  in  the 
latter  years  of  life,  at  least,  they  have  been  very  abstemious  in  the 
use  of  meat.  In  fact,  Nature  usually  furnishes  a  hint  in  this  direc- 
tion by  depriving  them  of  their  teeth,  making  it  practically  impos- 
sible to  eat  animal  food,  which  requires  mastication,  and,  as  Yeo  sug- 
gests, "  if  artificial  teeth  are  used  for  the  purpose  of  continuing  a 
diet  composed  of  animal  flesh,  they  will  not  prove  an  unqualified 
advantage." 

Next  in  importance  to  diminishing  the  quantity  of  food  in  the 
diet  of  the  aged  (especially  the  proportion  of  protein)  should  be 
considered  the  necessity  of  regularity  in  diet,  both  in  regard  to  the 
general  character  of  the  food  taken  and  the  times  of  eating. 

If  the  teeth  are  absent,  tough  vegetables  and  meats  should  be 
avoided,  yet  the  food  should  not  be  exclusively  fluid,  for  some  mastica- 
tion should  be  performed  in  order  to  maintain  the  salivary  flow. 
Plenty  of  time  should  be  allowed  for  this  purpose. 

Any  sudden  changes  in  diet  should  be  avoided,  and  the  intervals 
between  the  ingestion  of  food  should  not  exceed  six  hours. 


356  SPECIAL  CONDITIONS  INFLUENCING  FOODS 

It  is  common  for  elderly  people  to  awaken  in  the  morning  at  three 
or  four  o'clock  and  be  unable  to  sleep  again,  but  if  they  have  some 
light  form  of  nourishment  at  the  bedside,  such  as  a  glass  of  milk 
or  a  little  gruel,  which  they  can  take  at  that  time,  they  often  may 
continue  their  sleep.  I  have  found  the  vacuum  or  "  thermos  "  bot- 
tle of  service  in  such  cases.  It  is  a  double  bottle  with  a  vacuum  be- 
tween the  walls  which  acts  as  a  nonconductor  of  both  heat  and  cold. 
Fluids  poured  into  it  retain  their  temperature  for  a  dozen  hours  or 
more;  hence  hot  milk  or  bouillon,  etc.,  may  be  obtained  at  any  hour 
without  the  trouble  of  heating  it  at  inconvenient  hours. 

Malt  liquors  are  very  good  for  the  aged,  and  a  moderate  amount 
of  alcoholic  drink  acts  as  a  tonic  and  supplies  them  with  needed 
energy  for  digestion  and  other  functions. 

Yeo  gives  the  following  suggestions  in  regard  to  the  diet  of  the 
aged,  which  are  so  useful  that  they  will  be  quoted  in  full: 

"  Of  animal  foods  best  suited  for  this  time  of  life  the  following 
may  be  mentioned.  When  the  organs  of  mastication  are  altogether 
inefficient  these  foods  should  be  minced  or  pounded  into  a  paste  or 
otherwise  finely  subdivided: 

"  Young,  tender  chicken,  game  and  other  tender  meats. 

"  Minced  chicken,  game,  and  others  meats,  sweetbread. 

"White  fish,  as  soles,  whiting,  smelts,  flounders,  etc.  Best  when 
boiled. 

"  Bacon,  grilled ;  eggs  lightly  cooked  or  beaten  up  with  milk. 

"  Xutriftous  soups,  such  as  chicken  or  fish,  beef  tea,  mutton  and 
chicken  broths. 

"  Milk  in  all  forms,  when  easily  digested. 

"  Beef  tea  and  milk  supply  the  needed  mineral  substances,  and 
the  former  is  an  excellent  stimulant. 

"  The  addition  to  milk  of  an  equal  quantity  of  warm  Vichy,  or  of 
warm  water,  will  often  help  to  make  it  agree. 

"Of  vegetable  foods  the  following  are  all  suitable : 

"  Bread  and  milk  made  with  the  crumb  of  stale  bread  and  with- 
out any  lumps.  Porridge  and  oatmeal  gruel.  Puddings  of  ground 
rice,  tapioca,  arrowroot,  sago,  macaroni  with  milk  or  eggs  and  fla- 
vored with  warm  spices,  or  served  with  fruit  juice  or  jelly;  bread 
and  butter,  at  least  a  day  old;  rusks  for  soaking  in  tea,  or  milk,  or 
water. 

"  Artificial  foods,  consisting  of  predigested  starches.  The  diges- 
tive ferments  are  scantily  provided  by  the  digestive  organs  at  this 
age,  and  soluble  carbohydrates  are  valuable  for  maintaining  the  body 
heat. 


DIET  AND   HEREDITY  357 

"All  farinaceous  foods  should  be  submitted  to  a  high  temperature 
for  some  time,  so  as  to  render  the  starch  granules  more  easy  of 
digestion. 

"  Vegetable  purees  of  all  kinds  may  be  taken  in  moderation  — 
e.  g.,  potatoes,  carrots,  spinach,  and  other  succulent  vegetables. 

"  It  is  important  that  the  use  of  potatoes  and  fresh  vegetables 
should  not  be  neglected;  otherwise  a  scorbutic  state  of  the  body  may 
be  engendered. 

"  Stewed  celery  and  stewed  Spanish  or  Portugal  onions.  Stewed 
or  baked  fruits  and  fruit  jellies  and  the  pulp  of  perfectly  ripe  raw 
fruits  in  small  quantity.  The  acidity  of  certain  stewed  fruits  may 
advantageously  be  neutralized  by  the  addition  of  a  little  bicarbonate 
of  soda  so  as  to  avoid  the  use  of  a  large  quantity  of  cane  sugar  to 
sweeten  it,  as  this  is  apt  to  cause  gastric  fermentation  and  acidity. 
In  stewing  fruit,  about  as  much  soda  as  will  cover  a  shilling  should 
be  added  to  each  pound  of  fruit. 

"  Aged  persons  often  require  their  foods  to  be  accompanied  with 
some  kind  of  condiment,  which  promotes  their  digestion  and  prevents 
flatulence.  For  sweetening  food,  milk  sugar  is  much  less  prone  to 
excite  acid  fermentation  than  cane  sugar. 

"  A  very  digestible  form  of  fat  —  when  it  is  needed  —  is  cream, 
mixed  with  an  equal  quantity  of  hot  water  and  about  ten  drops  of 
sal  volatile  to  each  fluid  ounce." 

DIET  AND  HEREDITY 

The  influence  of  heredity  upon  diet  is  not  very  striking.  Children 
are  sometimes  supposed  to  inherit  likes  and  dislikes  for  particular 
foods,  whereas  they  are  merely  acquired  tastes  from  the  circum- 
stance that  they  have  certain  foods  offered  them  at  home  to  the 
exclusion  of  others.  The  functions  of  the  stomach  and  intestines 
appear  to  be  somewhat  hereditary.  Violent  "seasickness,"  as  well 
as  a  tendency  to  biliousness  and  constipation  in  some  persons  and  the 
prompt  vomiting  of  the  contents  of  an  overloaded  stomach  in  others 
is  sometimes  a  family  trait,  running  through  three  or  four  genera- 
tions. So  is  occasionally  the  inability  to  digest  special  foods,  such 
as  crustaceans,  milk,  strawberries,  etc.,  but  such  instances  are  rare. 

Unfortunately,  the  abuse  of  alcohol  is  very  strongly  hereditary  — 
so  much  so  that  the  children  of  inebriate  parents  should  be  protected 
as  long  as  possible  from  learning  the  taste  of  either  beer,  wine,  or 
spirits. 

Heredity   has    some    influence   in    disorders   of    food   assimilation, 


358  SPECIAL  CONDITIONS  INFLUENCING  FOODS 

like  gout  and  diabetes,  and  in  such  cases  improper  diet  and  careless 
habits  of  eating  may  develop  latent  disease. 

Stoutness  and  leanness  are  conditions  modified  to  some  extent  by 
heredity,  as  well  as  many  other  factors. 


DIET  AND  RACE 

The  food  of  prehistoric  man  necessarily  consisted  of  the  simplest 
elements,  represented  by  fruits,  berries,  nuts,  insects,  and  an  occa- 
sional piece  of  raw  fish  or  meat.  Such  food  is,  in  fact,  the  diet  of 
primitive  tribes  to-day.  The  Fuegian  lives  chiefly  upon  shellfish 
and  seaweeds,  and  the  Central  African  dwarf  upon  plantains  and 
insects  (see  p.  371).  The  name  "Eskimo"  was  first  applied  by 
natives  of  eastern  Canada  in  opprobrium,  to  signify  "  raw-fish  eater." 

The  history  of  the  development  of  diets  and  of  food  cultivation 
and  preparation  is  practically  a  history  of  the  progress  of  culture, 
and  most  of  our  present  foods  were  quite  unknown  to  our  earliest 
progenitors.  The  discovery  of  the  uses  of  fire  greatly  increased 
the  variety  of  available  foods  for  man,  for  all  the  cereals  which  are 
cultivated  require  its  use  to  fit  them  for  digestion.  As  Gerland  has 
said,  men  obtain  their  food  either  from  natural  products,  by  cultiva- 
tion, or  by  barter  and  commercial  exchange,  according  as  nomadic  or 
fixed  habits  predominate,  and  "  no  mere  hunting  or  fishing  tribe  can 
be  large  and  remain  in  one  place,"  for  it  is  estimated  that  in  the 
temperate  zone  to  support  one  man  by  these  means  at  least  sixteen 
square  miles  of  territory  are  necessary. 

Many  a  tribal,  and  even  national  war  has  been  the  more  or  less 
direct  outcome  of  the  necessities  of  obtaining  food  supply  from  dis- 
tant sources,  and  the  economic,  commercial,  and  social  development 
of  all  matters  pertaining  to  food  among  civilized  people  to-day  far 
exceeds  in  importance  all  other  practical  questions. 

Following  is  a  synopsis  of  an  exceedingly  interesting  report  writ- 
ten for  me  by  Dr.  Frederick  A.  Cook,  the  physician  to  the  Peary 
expedition  to  Northwestern  Greenland  in  1891-J92,  which  is  ap- 
pended to  illustrate  the  dietetic  habits  of  a  race  which,  for  nearly 
a  thousand  years,  are  believed  to  have  been  practically  isolated  from 
commercial  or  social  relations  with  any  of  their  neighbors.  One 
cannot  peruse  the  account  without  being  impressed  with  the  fact 
that  generalizations  in  regard  to  the  influence  of  diet  upon  the  sys- 
tem should  lie  made  with  great  caution  when  applied  to  different 
races  of  man.  For  example,  both  scurvy  and  rheumatism  are  some- 
times attributed  to  an  excessive  meat  diet,  yet  the  Eskimo  has  al- 


DIET   AND   RACE  359 

most  no  starchy  food  and  does  not  suffer  from  these  diseases,  and, 
moreover,  his  bodily  vigor  and  power  of  endurance  compare  favorably 
with  that  of  any  other  race  or  class  of  men,  and  in  some  respects 
it  is  greater. 

Dr.  Cook  says  in  regard  to  the  Eskimos  of  Northwestern  Green- 
land :  "  They  usually  eat  but  one  meal  a  day,  which  they  take  at 
irregular  times,  being  people  without  restrictions  of  any  kind.  They 
can  be  seen  eating  and  drinking  whenever  able  to  procure  suste- 
nance. Their  diet  consists  almost  exclusively  of  meat,  composed 
principally  of  the  muscular  tissues  of  the  following  animals,  in  the 
order  of  their  importance  to  the  natives:  Seal,  walrus,  norwhale, 
white  whale,  polar  bear,  reindeer,  arctic  hare,  and  sea  fowls,  such 
as  guillemots,  gulls,  eider  ducks,  etc.  When  food  is  scarce  they 
eat  every  part  of  the  animal,  including  the  stomach  and  intestines; 
indeed,  the  only  vegetable  food  that  the  most  northern  Eskimo  can 
obtain  consists  of  the  contents  of  the  stomach  of  the  reindeer 
(lichens),  which  he  is  only  occasionally  able  to  secure.  The  women 
and  children  sometimes  eat  flowers  of  the  arctic  poppies  and  the 
so-called  scurvy  grass,  but  never  to  any  great  extent.  In  times  of 
famine,  in  order  to  prevent  wholesale  starvation,  the  aged  are  turned 
out  to  starve  to  death,  and  their  bodies  are  then  devoured  by  the 
more  vigorous  members  of  the  tribe.  Occasionally,  when  the  old 
people  are  shrewd  and  active,  the  younger  children  are  sacrificed 
for  this  purpose.  As  a  rule,  the  Eskimo  will  not  eat  dogs,  but  when 
food  is  scarce  dogs  are  first  added  to  their  larder,  and  when  the 
last  dog  has  been  eaten,  human  beings  come  next  in  order. 

"  One  of  the  greatest  delicacies  is  old  seal.  A  native  never  wastes 
the  carcass  of  an  animal ;  if  he  should  kill  the  seal  fifty  or  a  hundred 
miles  from  home  he  will  bring  it  to  shore  and  cache  it  in  such  a 
way  that  the  foxes,  bears,  and  birds  cannot  attack  it.  He  then  leaves 
it,  and  may  not  return  for  two  or  three  years,  when  he  comes  back 
in  anticipation  of  a  great  feast,  for  the  old  seal  seems  to  him  like 
old  cheese  to  us,  and  he  enjoys  it  immensely,  although  a  white  man 
could  not  endure  the  odor. 

"  Fully  two-thirds  of  the  Eskimo  food  is  eaten  raw,  and  one- 
half  is  consumed  while  in  the  frozen  state.  When  an  Eskimo  woman 
starts  her  blubber  lamp  and  places  over  it  a  conlipsie  (the  name 
applied  to  their  primitive  stew  pot),  she  does  so  principally  to  obtain 
the  warm  drink  which  the  cooked  meat  affords.  It  cannot  be  said 
that  Eskimos  cook  their  meat  because  they  prefer  it  cooked,  but 
because  when  the  meat  is  heated  slowly,  as  it  can  only  be  heated 
by  their  primitive  method,  the  blood  and  fat  ooze  from  the  mus- 


360  SPECIAL  CONDITIONS  INFLUENCING  FOODS 

cular  tissues  and  form  a  thick  soup,  which,  aside  from  water,  is 
almost  their  only  drink,  and  a  cupful  of  this  beverage  is  offered 
to  every  guest.  The  natives  may  consume  three  or  four  hours  in 
eating  one  meal,  and  when  they  have  thoroughly  gorged  themselves 
they  will  lie  down  and  sleep;  as  they  do  this,  however,  they  place 
before  themselves  a  dish  full  of  cooked  meat,  and  those  who  awake 
from  their  sleep  will  finish  their  meal,  but  on  rising  no  breakfast  is 
served,  for  the  Eskimo  who  has  a  day's  journey  before  him  would 
not  think  of  eating  before  starting.  He  claims  that  this  would 
prevent  his  ability  to  travel,  and  this  rule  the  Eskimos  apply  to 
their  dogs  as  well,  who  are  often  fed  only  every  two  days. 

"  The  Eskimos  endure  fasting  very  well,  and  after  a  good,  full 
meal  they  can  fast  for  two  or  three  days,  apparently  without  serious 
inconvenience.  But  they  appreciate  the  fact  that  he  who  is  not 
well  fed  cannot  encounter  fierce  storms,  and  no  one  who  has  not  had 
full  rations  would  think  of  venturing  out  in  severe  weather.  During 
the  tedious  night  of  four  months  these  Eskimos  appear  to  undergo  a 
state  of  hibernation,  eating  very  little  and  sleeping  a  great  deal; 
their  otherwise  lively  spirits  are  more  or  less  subdued,  and  while 
they  try  to  keep  cheerful  they  are  apt  to  become  depressed  and  debil- 
itated, and  are  not  capable  of  great  muscular  exercise  during  this 
time. 

"  The  Eskimo  drinks  very  little  while  eating.  He  usually  defers 
that  for  some  time  afterwards,  or  perhaps  until  he  arises  next  morn- 
ing, when  he  drinks  a  great  deal,  and  while  I  have  not  measured 
the  quantity  of  water  consumed  by  any  definite  number  of  inches 
in  twenty-four  hours,  I  have  often  given  Eskimo  men  three  pints 
of  water  at  one  time,  and  nursing  women  two  quarts.  Before  start- 
ing upon  a  journey  a  native  will  fill  up  with  water.  It  should  be 
remembered  that  these  people  use  no  free  salt  or  condiments. 

"  I  am  not  prepared  to  say  that  the  food  of  these  people  bears 
any  relation  to  their  stature,  as  other  factors  may  influence  their 
height,  but  their  large  abdominal  development  is  undoubtedly  due 
to  the  immense  quantity  of  food  and  drink  which  they  consume  at 
one  time.  Variation  in  diet  does  not  seem  to  be  a  necessity  to  the 
Eskimo  unless  he  is  feeling  ill,  when  he  recognizes  the  importance 
of  a  change  of  food  and  surroundings. 

"  The  Eskimo  mother  nurses  her  child  until  the  next  is  born  or 
shortly  before  it,  a  period  which  varies  from  one  to  eight  or  nine 
years,  but  the  average  time  is  four  years.  Long  before  the  mother 
weans  her  child  she  masticates  the  food,  opens  the  baby's  mouth, 
and  transfers  the  food  from  her  own  mouth  to  the  baby's,  very  much 


DIET   AND  RACE 


361 


as  a  pigeon  does,  and  the  child  thus  brought  up  would  not  think  of 
taking  up  pieces  of  meat  or  toys  or  anything  else  to  put  into  its 
mouth,  for  it  will  take  nothing  except  from  its  mother. 

"  The  average  weight  of  these  northern  Eskimo  men  is  one  hun- 
dred and  thirty-five  pounds,  but  that  of  the  women  one  hundred  and 
thirty-eight  pounds.  Obesity  is  foreign  to  the  Eskimo,  and  lean- 
ness is  equally  rare." 

Studies  of  negro  diet  have  been  made  for  the  United  States  De- 
partment of  Agriculture  by  H.  B.  Frissell  and  Isabel  Bevier,  with 
the  following  result: 

Cost,  Nutrients,  and  Fuel  Value  of  Food  per  Man  per  Day  in  Dietary  Studies 
in  Virginia  and  Elseichere. 


Pro- 
tein. 

Fats. 

Carbo- 
hydrates. 

Fuel 
value. 

DIETARIES  OF  NEGROES  IN  ALABAMA 

Dietary  with  minimum  protein   

Grams. 

26 
99 
31 
93 

62 
109 

Grams. 

83 

252 
27 
283 
132 
159 

Grams. 
225 
666 
304 
649 
436 
444 

Calories. 
1,800 
5,480 
1,625 
5,670 
3,270 
3,745 

Dietary  with  maximum  protein  

Dietary  with  minimum  energy   

Dietary  with  maximum  energy  

Average  of  20  negro  families  in  Alabama  .  .  . 
Average  of  19  negro  families  in  Virginia   .  .  . 

Tentative  standard  for  man  at  moderate  work 

125 

... 

3,500 

The  preponderance  of  protein  in  the  diet  of  Virginia  negroes  as 
compared  with  those  investigated  in  Alabama  is  due  to  residence 
nearer  the  sea  and  large  consumption  of  fish,  especially  salt  herring. 

Arthur  Goss  (Xutrition  Investigations  in  New  Mexico,  U.  S.  De- 
partment of  Agriculture)  gives  the  following  dietary  of  a  Mexican 
living  in  Xew  Mexico  and  an  Alabama  negro: 


NUTRIENTS  IN  GRAMS. 

Fuel  value  in 
calories. 

Protein. 

Fats. 

Carbohydrates. 

68 
62 

73 
132 

572 
436 

3,320 
3,270 

In  this  dietary  the  Mexican  subsists  upon  little  more  than  half 
of  the  standard  requirement  of  protein,  and  the  negro  upon  less 
than  one-half.  The  Mexican  eats  chiefly  flour  and  frijoles,  with 
little  meat,  and  the  negro  subsists  upon  bacon,  fish,  and  cornmeal. 

Eacial  peculiarities  in  diet  are  often  not  referable  to  any  inherent 
peculiarity  in  race,  but  rather  to  environment.  Man  naturally  eats 
26 


362  SPECIAL  CONDITIONS  INFLUENCING  FOODS 

what  he  can  obtain  easiest  in  the  locality  in  which  he  lives,  and  if 
he  has  not  attained  to  a  degree  of  civilization  in  which  commercial 
interchange  brings  him  a  variety  of  foods  foreign  to  his  locality, 
his  diet  remains  restricted.  With  changed  surroundings  also,  he 
promptly  modifies  many  of  his  racial  food  habits,  as  proved  by  ex- 
perience with  the  Chinese,  Bohemian,  Italian,  Mexican  and  other 
classes  of  immigrants  to  this  country,  as  studied  by  the  numerous 
State  Agricultural  Experiment  Stations. 


PART  V 

FOOD   DIGESTION  —  CONDITIONS   WHICH   ESPECIALLY 
AFFECT  DIGESTION 


IN  the  previous  part  of  this  work  there  have  been  incorporated 
a  number  of  tables  of  the  so-called  "nutrient  values"  of  foods  as 
computed  by  physiological  chemists.  Such  analyses  are  of  unques- 
tioned scientific  interest,  but  it  is  necessary  to  caution  against  their 
too  rigorous  application  in  practical  feeding,  either  in  health  or 
disease.  For  example,  as  pointed  out  by  Halliburton,  pork  is  the 
most  highly  nitrogenous  of  meats  by  analysis,  yet  its  muscular  fibers 
are  so  associated  with  fat  that  much  of  this  food  fails  to  be  acted 
upon  by  the  digestive  agents  of  the  body,  and  passes  out  as  waste. 
Similarly  whole  wheat  bread  is  chemically  more  nutritious  than 
the  bread  of  refined  flour,  yet  so  much  of  the  proteid-bearing  bran 
is  undigested,  that  bulk  for  bulk,  the  whole-wheat  breads  are  much 
less  nutritious.  As  Halliburton  states,  "a  common  error,  which  it 
seems  impossible  to  dislodge  from  the  medical  mind,  is  that  'nu- 
tritive '  and  '  nitrogenous '  are  synonymous  terms." 

Another  example  is  found  in  the  application  of  analyses  of  red 
versus  white  meats  to  the  feeding  of  patients  with  enfeebled  diges- 
tion. The  differences  in  proteid  content  and  extractives  may  be 
very  slight,  yet  the  variation  in  toughness  of  fiber  and  consequent 
digestibility  may  be  considerable. 

For  such  reasons  I  desire  particularly  to  emphasize  that  it  is  wholly 
impracticable  to  prescribe  an  invalid  dietary  on  a  strict  basis  of 
"  calories "  as  representing  energy,  or  heat,  or  a  matter  of  storage 
of  body  substance,  as  one  would  definitely  prescribe  a  medicine.  More- 
over, for  obvious  reasons,  nearly  all  the  calorifacient  food  experi- 
ments made  with  man  have  been  conducted  upon  those  in  health, 
not  in  disease.  Even  a  healthy  man  inclosed  in  a  calorimeter  for  a 
few  days'  experimentation  is  in  reality  under  highly  artificial  con- 
ditions as  compared  with  a  healthy  man  under  stress  of  mental 
work,  physical  labor  out  doors,  or  subjected  to  any  of  the  manifold 
changing  conditions  of  daily  life. 

363 


364  FOOD   DIGESTION 

In  the  ensuing  chapters,  therefore,  the  conditions  especially  af- 
fecting food  digestion  and  the  true  nutrient  value  of  food  in  dis- 
ease will  be  considered  from  practical  and  clinical  standards,  without 
placing  undue  emphasis  upon  analyses  and  "calories." 

Patients  often  conceive  erroneous  ideas  regarding  the  digestibility 
of  special  foods.  The  food  supposed  to  "  disagree  "  may  have  done 
so  because  it  has  been  improperly  prepared  or  cooked,  or  because 
it  has  been  eaten  with  other  foods  forming  improper  combinations. 
For  example,  an  exclusive  milk  diet  may  be  well  tolerated,  whereas 
the  milk  taken  with  other  foods  may  produce  dyspepsia  or  bilious- 
ness. Moreover,  it  is  quite  possible  that  a  food  which  at  one  time 
proved  indigestible,  may  have  done  so  because  of  transient  abnormal 
conditions  in  the  digestive  apparatus,  rather  than  from  any  injurious 
quality  in  the  food  itself.  Finally,  digestion  often  varies  much  in 
the  same  healthy  person  at  different  epochs  of  life. 

HOURS  FOR  MEALS  AND  ORDER  OF  TAKING  FOOD 

The  hours  for  taking  meals  which  are  commonly  selected  are  those 
which  are  best  adapted  to  the  varying  needs  of  the  system  at  dif- 
ferent times  in  the  day,  and  experience  teaches  that  they  should  be 
varied  considerably  with  occupation.  In  the  larger  American  cities 
where  commerce  is  active,  and  many  men  are  subjected  during  the 
day  to  excitement,  hurry,  and  strain,  an  evening  dinner  hour  often 
best  meets  the  needs  of  the  system  as  well  as  the  requirements  of 
personal  convenience.  In  the  rural  districts,  however,  and  in  many 
countries  where  life  is  less  hurried  and  active  than  under  the  condi- 
tions of  the  extraordinary  rapid  growth  and  development  of  the 
United  States,  it  is  found  that  taking  the  heaviest  meal  at  noon 
agrees  better  with  the  wants  of  most  persons. 

The  proper  hours  for  infant  feeding  are  described  under  the  head- 
ing Infant  Feeding.  Children  should  always  dine  early  in  the 
day.  There  are  in  general  three  systems  for  adults  in  regard  to  the 
number  of  meals  and  hours  for  taking  them  which  are  in  common 
use,  in  which  two,  three,  and  four  meals,  respectively,  are  eaten  in 
the  twenty-four  hours. 

The  first  system,  which  is  in  vogue  in  France  and,  to  a  less  extent, 
elsewhere,  is  that  of  eating  only  two  substantial  meals  a  day.  On 
first  rising  in  the  morning,  a  cup  of  hot  coffee  or  chocolate  is  taken 
with  a  roll  or  some  other  simple  form  of  bread.  This  enables  two  or 
three  hours  of  moderate  work  to  be  accomplished  before  the  first 
real  meal,  which  i>  a  breakfast  eaten  in  the  late  morning,  usually 


HOURS  FOR  MEALS  365 

at  or  before  twelve  o'clock.  This  meal  is  substantial,  consisting  of 
several  courses  of  solid  food.  The  second  meal,  which  is  the  dinner, 
is  usually  eaten  between  six  and  seven  o'clock.  This  system  is  in 
use  among  workingmen  as  well  as  with  the  leisure  classes,  and  is 
found  well  adapted  to  their  habits  of  life.  Americans  traveling 
abroad,  who  are  accustomed  to  eat  a  heavier  meal  for  early  break- 
fast, often  experience  difficulty  in  adapting  themselves  to  the  French 
custom,  but  many  learn  to  like  it,  and  as  the  traveling  public  are 
commonly  for  the  time  being,  a  leisure  class,  it  is  less  difficult  to 
adapt  themselves  to  new  customs  abroad  than  to  introduce  them  at 
home. 

The  Germans  also  usually  take  a  cup  of  coffee  or  other  light 
beverage  and  a  roll  or  Butter-brod  soon  after  rising,  but  they  dine 
very  early,  often  at  half-past  twelve,  taking  a  heavy,  deliberate  meal 
at  this  hour,  which  they  are  apt  to  follow  with  beer  and  tobacco. 
Their  offices  and  banks  open  early,  and  are  often  closed  from  noon 
until  three  o'clock,  when  they  are  reopened  until  five,  whereas  in 
most  cities  in  this  country  the  most  active  business  hours  are  in 
the  middle  of  the  day,  and  it  would  be  practically  impossible  for 
many  men  to  give  up  two  or  three  hours  at  this  time  to  eating  and 
social  converse.  The  Germans  usually  take  a  supper  with  meat  at 
a  somewhat  late  hour  —  between  half-past  seven  and  eight  o'clock. 
In  many  German  towns  it  is  customary  to  open  the  theaters  as  early 
as  six  o'clock,  so  that  the  performance  is  closed  in  time  for  a  supper 
at  nine.  The  habit  of  eating  between  meals  and  of  taking  occasional 
light  lunches  in  the  afternoon  seems  to  be  more  prevalent  there  than 
elsewhere. 

In  England  it  is  a  very  common  custom  for  the  better  classes 
to  breakfast  at  eight  or  nine  o'clock,  lunch  between  one  and  two, 
take  a  cup  of  tea  and  perhaps  a  biscuit  at  four  or  five,  and  dine  at 
eight  o'clock. 

In  the  United  States,  where  there  are  theoretically  no  class  dis- 
tinctions, they  practically  do  exist  very  strikingly  in  regard  to  the 
hours  for  taking  meals,  and  the  hard-working  laboring  class,  whether 
employed  in  the  city  or  country,  almost  universally  dine  at  noon, 
at  least  when  they  can  return  home  for  their  meals.  It  is  mainly 
the  mercantile  and  professional  classes  in  large  cities  who  dine  be- 
tween 6  and  7  p.  M.,  while  the  more  fashionable  or  leisure  classes 
dine  later  —  often  at  eight  o'clock.  Many  of  the  latter,  however,  on 
going  to  the  country  for  a  summer  holiday,  reverse  their  habits  and 
dine  at  the  usual  country  hour  —  at  one  o'clock,  taking  supper  at 
half-past  six  or  seven.  In  the  Southern  cities  it  is  common  to  dine 


366  FOOD  DIGESTION 

in  the  neighborhood  of  half -past  two  or  three  o'clock.  Many  persons 
in  cities  who  habitually  dine  late  on  week  days  from  long-continued 
custom,  on  Sundays  dine  shortly  after  noon,  taking  supper  in  the 
evening.  This  is  an  old  custom  handed  down  from  days  in  which 
less  exacting  occupations  favored  noon  dining  throughout  the  week, 
but  due  in  part  also  to  economic  reasons,  and  a  desire  to  make  the 
work  for  servants  as  light  as  possible  on  Sunday  afternoon.  While 
those  in  good  health  with  active  digestion  suffer  no  inconvenience 
from  thus  changing  the  hour  for  meals  on  one  day  in  the  week, 
there  are  others  who  find  that  it  disagrees  with  them  and  disturbs 
their  digestion.  A  hearty  meal  at  noon  following  a  very  light  break- 
fast, consisting  of  a  roll  and  cup  of  coffee  or  tea,  may  be  digested  per- 
fectly for  years,  yet  reversing  the  order  of  meals  may  entirely 
disorder  the  digestion. 

For  professional  and  other  classes  of  men  in  the  United  States 
who  are  not  occupied  in  physical  labor  or  outdoor  pursuits  the 
following  system  is  found  to  possess  decided  advantages:  A  break- 
fast is  taken  soon  after  rising,  at  half-past  seven  to  half-past  eight, 
which  consists  of  fresh  fruit,  porridge  or  oatmeal,  or  other  variety 
of  cereals,  poached  eggs  or  omelet,  and  a  little  bacon  or  fresh  or 
salt  fish,  bread  and  butter,  tea  or  coffee.  The  lunch,  eaten  between 
one  and  two  o'clock,  may  consist  of  a  lean  chop,  or  a  piece  of  cold 
ham,  or  a  slice  of  rare  beef  with  stewed  or  baked  potatoes,  and  a 
simple  lettuce  salad,  or  perhaps  a  little  cheese  or  light  pudding,  for 
dessert.  If  a  heavy  meal  be  taken  at  this  hour  by  persons  unac- 
customed to  it,  and  who  have  had  a  breakfast  of  solid  food,  they 
often  feel  dull  and  sleepy  for  an  hour  or  two  thereafter,  and  are 
consequently  incapacitated  from  active  mental  work.  The  dinner 
should  be  from  half-past  six  to  half-past  seven,  after  the  principal 
labors  of  the  day  are  over,  and  at  an  hour  early  enough  to  allow 
of  the  complete  digestion  of  the  heaviest  meal  of  the  day  before  re- 
tiring. This  may  consist  of  several  courses,  which  are  conventionally 
arranged  in  the  order  which  appears  to  be  most  rational  and  phys- 
iological —  namely,  soup,  fish  or  an  entree.,  a  steak  or  joint  with 
potatoes  and  one  or  two  fresh  vegetables,  a  salad,  and  a  pudding 
or  cooked  fruit. 

Order  of  Dinner  Courses. —  A  clear  soup  at  the  commencement  of 
a  meal  promotes  digestion.  The  fluid,  if  taken  in  a  quantity  not 
exceeding  eight  or  ten  ounces,  for  the  greater  part,  is  promptly 
absorbed  in  the  stomach,  and  its  warmth  and  the  sustenance  it  con- 
tains act  favorably  upon  the  circulation,  stimulate  the  secretion  of 
gastric  juice,  and  satisfy  temporarily  the  cravings  of  hunger  which 


HOURS  FOE   MEALS  367 

are  not  met  by  the  taking  of  solid  food  until  after  it  has  been 
digested  for  some  time.  The  fish  or  entree  is  then  eaten  in  the 
earlier  stage  of  gastric  secretion  when  the  gastric  juice  has  not  yet 
attained  its  full  strength  and  quantity.  This  is  followed  by  the  eat- 
ing of  meat,  which  is  destined  to  remain  in  the  stomach  for  two 
hours  or  more,  and  requires  all  the  energy  of  digestive  processes. 
The  saccharine  or  farinaceous  food,  which  does  not  undergo  diges- 
tion in  the  stomach,  is  taken  towards  the  end  of  the  meal,  when  it 
remains  a  less  time  in  the  stomach  than  animal  food. 

The  discussion  of  more  elaborate  dinners,  consisting,  as  they 
do  very  often,  of  a  dozen  or  more  separate  courses,  would  be  out 
of  place  in  this  volume.  Such  dinners  can  only  be  indulged  in  for 
any  length  of  time  by  those  whose  digestion  is  robust  and  whose 
leisure  and  comparative  freedom  from  care  and  anxiety  allow  them 
to  devote  abundant  time  and  physical  energy  to  their  meals  and  to 
secure  sufficient  holidays  and  trips  to  noted  spas  to  enable  them 
to  periodically  relieve  the  digestive  system  of  the  strain  put  upon 
it.  Persons  who  rise  late  and  dine  early  should  eat  a  small  break- 
fast and  a  hearty  supper.  If  the  noon  dinner  is  replaced  by  a  light 
luncheon,  a  substantial  breakfast  should  be  eaten. 

Undoubtedly  it  is  usually  best  so  to  order  one's  occupation  that 
neither  severe  mental  nor  physical  labor  need  be  undertaken  im- 
mediately after  eating.  Yet  much  depends  upon  the  age  and  strength 
of  the  individual. 

At  one  of  the  largest  colleges  for  girls  in  New  England  the  pupils 
dine  at  one  o'clock,  and  many  of  them  commence  to  study  im- 
mediately thereafter,  or  at  2  P.  M.  ;  yet  cases  of  indigestion  are  com- 
paratively infrequent  among  them;  and  the  ordinary  day  laborer 
begins  his  work  again  without  detriment  almost  immediately  after 
a  hearty  noon  meal,  and  continues  it  while  gastric  and  intestinal 
digestion  are  still  necessarily  incomplete. 

Invalids  often  require  modification  in  the  accustomed  hours  for 
meals,  and  Balfour  says  that  "all  invalids  should  have  their  im- 
portant meal  in  the  middle  of  the  day." 

Between  three  and  four  hours,  on  the  average,  should  be  regarded  as 
necessary  for  complete  digestion  of  a  mixed  meal. 

The  intervals  between  meals  should  be  regulated  with  reference 
to  individual  peculiarities.  As  a  general  rule,  convalescents  or  per- 
sons with  feeble  digestive  powers  and  poor  appetites,  who  are  unable 
to  eat  a  sufficient  quantity  of  food  at  any  one  meal,  should  be  fed 
more  frequently,  perhaps  four  or  five  times  a  day  —  that  is,  in  ad- 
dition to  three  ordinary  meals,  they  should  have  light  lunches  in 


368  FOOD  DIGESTION 

the  middle  of  the  forenoon  and  afternoon,  or  possibly  just  before 
retiring.  The  latter  is  particularly  to  be  recommended,  for  if  the  food 
be  light  and  nutritious,  such  as  a  bowl  of  gruel  and  a  glass  of  hot 
milk,  or  a  cup  of  cocoa  with  a  biscuit,  and  possibly  a  glass  of  beer, 
sleep  is  not  interfered  with,  but  is  promoted,  and  the  system  is  saved 
from  too  long  an  interval  of  starvation  between  the  hours  of  din- 
ner or  supper  and  breakfast.  On  the  other  hand,  dyspeptics  and  pa- 
tients with  gastric  catarrh  may  find  it  desirable  to  allow  an  interval 
of  fully  seven  hours  between  their  meals,  in  order  to  give  abundant 
time  for  the  digestion  of  one  meal  before  that  of  the  next  is  under- 
taken, and  they  should  stop  eating  short  of  repletion. 

There  are  others  whose  digestion  is  good,  but  constitutionally  slow, 
and  they  are  better  with  intervals  of  at  least  six  hours  between 
their  meals;  and  there  are  some  persons  who  maintain  better  health 
on  only  two  meals  a  day,  and  occasionally,  although  it  must  be 
regarded  as  an  eccentricity  (except  in  the  case  of  some  savages  and 
the  Eskimos)  (see  p.  359),  there  are  persons  who  thrive  upon  only 
one  meal  a  day. 

The  monks  of  La  Trappe  eat  but  one  meal  daily,  as  a  religious 
custom,  at  which  they  consume  so  much  food  that  they  become  dull 
and  lethargic  for  several  hours  afterwards  (Combe). 

Many  savages,  like  the  Hottentots,  have  no  regular  times  for 
eating,  but,  like  the  carnivores,  take  their  food  whenever  and  how- 
ever they  can  best  obtain  it. 

The  business  or  professional  man,  when  overworked,  sometimes 
forms  the  habit  of  omitting  his  noon  luncheon;  but  this  custom, 
although  it  may  benefit  some  forms  of  dyspepsia,  is  a  pernicious  one 
in  the  majority  of  instances  if  long  continued. 

APPETITE 

The  term  "  appetite "  in  relation  to  dietetics  usually  means  a 
pleasurable  desire  for  food  or  drink,  whereas  hunger  and  thirst  im- 
ply a  craving  for  food  and  drink  respectively,  which  has  become 
disagreeable  or  positively  painful.  There  is,  however,  no  distinct 
line  of  demarcation  to  be  drawn  between  these  terms. 

The  appetite  for  food  is  a  most  capricious  sensation,  subject  to 
all  manner  of  disturbing  influences.  It  is  to  some  extent  appar- 
ently under  control  of  the  will,  in  that  it  can  be  trained  to  recur  at 
certain  intervals  before  taking  food.  In  a  normal  state  it  is,  there- 
fore, rhythmical,  and  it  may  then  be  taken  as  an  index  of  the  need 
of  food,  but  when  it  becomes  abnormal  it  is  a  very  unreliable  guide. 


APPETITE  369 

"  As  a  general  rule,  though  by  no  means  without  exception,  sub- 
stances pleasing  to  the  jpalate  are  useful  and  not  injurious  to  the 
organism"  (Lauder  Brunton). 

The  appetite  often  appears  with  great  suddenness,  either  inde- 
pendently or  as  the  result  of  directing  the  attention  to  matters  of 
food  and  eating.  It  may  depart  as  suddenly,  even  without  gratifica- 
tion, or  it  may  vanish  after  the  first  few  mouthfuls  of  food  are 
eaten,  although  it  was  apparently  vigorous  a  moment  before. 

The  appetite  is  aroused  by  a  variety  of  circumstances  and  con- 
ditions, both  physical  and  mental.  Such  are  the  smell,  taste,  and 
sight  of  food,  good  hygienic  surroundings,  exercise,  bathing,  cold 
or  stimulating  air,  agreeable  companionship,  pleasurable  mental  emo- 
tions, and  the  proper  preparation  and  serving  of  food.  It  may  be 
stimulated  by  bitters,  condiments,  such  salt  foods  as  caviare  or 
herring,  and  in  some  cases  by  alcohol.  Wine  drunk  between  meals 
is  apt  to  spoil  the  appetite,  but  taken  in  moderation  with  meals  it 
may  increase  it.  A  substance  known  as  orexine,  in  the  form  either 
of  a  hydrochlorate,  tannate,  or  simple  basic  condition,  has  been 
recommended  as  having  the  special  function  of  exciting  the  appe- 
tite in  convalescents.  It  does  not,  however,  give  uniform  results, 
and  I  have  seen  little  or  no  benefit  from  its  use. 

To  obtain  the  most  complete  satisfaction  from  the  sense  of  taste 
one  should  swallow  the  food,  and  not  merely  take  it  into  the  mouth. 
(Compare  "  Fletcherism,"  p.  384.) 

The  appetite  is  usually  somewhat  more  keen  in  winter  than  in 
summer,  but  many  persons  observe  no  difference,  and  if  the  winter 
be  spent  indoors  and  the  summer  in  outdoor  life,  the  condition  of 
appetite  may  be  reversed.  The  different  nature  of  summer  and 
winter  foods  causes  variations  in  appetite.  It  is  depressed  or  de- 
stroyed by  mental  emotion,  especially  grief,  anxiety,  and  worry; 
by  the  sight,  smell,  or  taste  of  ill-prepared  or  improperly  cooked 
or  badly  served  food;  foul  air  and  poor  hygienic  surroundings; 
fatigue  and  exhaustion;  many  diseases,  more  particularly  febrile 
diseases  and  most  gastric  disorders;  nausea;  the  abuse  of  strong 
condiments,  and  of  many  drugs,  notably  opium  and  those  which,  like 
potassium  iodide,  produce  a  continual  offensive  taste  in  the  mouth ; 
the  abuse  of  alcohol;  eating  irregularly  and  at  too  short  intervals. 
In  old  age  the  appetite,  especially  for  meats,  usually  becomes  less 
keen,  and  the  absence  of  teeth  contributes  to  the  loss  of  desire  for 
such  food. 

The  appetite  is  very  dependent  upon  habit  and  upon  the  usual 
order  and  arrangement  of  the  meal.  An  attempt  to  eat  a  lump  of 


370  FOOD   DIGESTION 

butter  alone  usually  fails,  but  it  is  easily  consumed  if  spread  upon 
bread.  Eeversing  the  customary  order  of  the  different  foods  served 
at  dinner  usually  produces  disgust,  and  may  even  excite  nausea. 

Pawlow  has  shown  by  a  series  of  elaborate  digestion  experiments, 
made  at  the  St.  Petersburg  Institute  of  Physiology,  that  there  are 
two  "tides"  of  gastric-juice  secretion.  The  first,  "appetite  juice," 
is  induced  by  hunger  and  the  pleasurable  sight  or  smell  of  food,  or 
the  sounds  associated  with  its  preparation,  and  is  psychic;  this  secre- 
tion is  abundant  and  actively  digestant.  The  second  is  excited  by 
the  mechanical  and  chemical  action  of  food  in  the  stomach.  Of  the 
two  the  former  often  proves  the  more  important,  for  food  which  is 
unappetizing,  or  food  which  for  any  reason  is  eaten  without  relish 
or  while  the  mind  is  strained  in  other  channels,  may  remain  for  hours 
undigested.  Hence  the  failure  oftentimes  to  secure  hydrochloric 
acid  after  an  unappetizing  "  test  meal "  of  bread  and  water. 

Bulimia,  which  means  excessive  craving  for  food,  is  by  no  means 
an  indication  of  vigor,  and  is  often  due  to  an  irritable  condition  of 
the  nerves  of  the  stomach  with  hyperacidity,  and  may  be  brought 
about  by  eating  at  irregular  intervals,  which  results  in  disturbance 
of  the  gastric  secretion.  A  voracious  appetite  sometimes  occurs  in 
children.  Such  children  are  usually  thin,  and  are  encouraged  by  ill- 
advised  parents  or  attendants  to  gorge  themselves  with  food  which 
they  do  not  digest.  It  is  common  among  the  epileptic,  insane,  es- 
pecially maniacs,  paranoiacs  and  the  degenerate.  (See  Appetite,  p. 
368,  and  Bulimia,  p.  370.) 

Abnormal  Food  Cravings 

Instances  of  abnormal  cravings  for  food  are  familiar  to  every 
one.  They  sometimes  take  the  form  merely  of  an  inordinate  desire 
for  food  which  is  in  itself  wholesome  but  which  is  poorly  adapted 
to  an  existing  diseased  condition.  Such  desire  is  liable  to  come  in 
the  course  of  any  protracted  illness  in  which  a  very  restricted  diet 
has  been  maintained  for  weeks.  It  is  largely  psychic,  and  does  not 
necessarily  indicate  an  increased  appetite.  The  dysenteric  patient 
may  long  for  ham  or  pickles  or  vegetables,  or  the  very  obese  will 
beg  for  sweets,  preserves,  or  farinaceous  food.  In  other  cases  the 
craving  may  be  an  indication  of  a  positive  want  in  the  system,  as 
when  a  scorbutic  patient  hungers  for  fresh  fruit  and  vegetable 
acids. 

In  no  disease  is  the  craving  for  food  of  every  kind  more  pro- 
nounced than  in  convalescence  from  typhoid  fever.  In  this  case  the 
hunger  can  hardly  be  considered  abnormal,  for  it  is  an  expression 


VAKIETY   IN  DIET  371 

of  the  need  of  wasted  and  exhausted  tissue  throughout  the  body  for 
nutriment. 

Patients  usually  find  it  most  difficult  to  give  up  the  class  of  foods 
which  they  well  know  does  them  most  harm.  The  victim  of  flatu- 
lent dyspepsia  longs  for  saccharine,  and  perhaps  amylaceous  or  fatty 
foods  —  confectionery,  pastry,  and  the  like  —  and  the  diabetic  often 
has  an  inordinate  craving  for  bread  or  sugar,  which  so  far  possesses 
him  as  to  cause  a  resort  to  any  subterfuge  to  obtain  it. 

In  disordered  mental  conditions,  hysteria,  hypochondriasis,  mel- 
ancholia, and  in  the  peculiar  periods  of  puberty,  pregnancy,  and  the 
menopause,  cravings  for  wholly  injurious  articles  may  arise.  Such 
patients  have  been  known  to  eat  chalk,  earth,  or  sour  food,  or  con- 
sume large  quantities  of  salt,  sodium  bicarbonate,  etc. 

With  the  exception  of  chronic  alcoholism  —  if  alcohol  be  regarded 
as  a  food  as  well  as  a  stimulant  —  there  is  no  distinct  food  "habit," 
in  the  sense  that  any  particular  food  is  likely  to  be  long  eaten  to  an 
injurious  excess.  Those  articles  of  diet  which  are  oftenest  abused  in 
this  manner  are  condiments,  especially  pepper  and  salt,  and  con- 
fectionery. 

VARIETY  IN  DIET 

Monotony  of  diet  is  not  incompatible  with  maintenance  of  life, 
and  even  of  health,  when  the  food  is  restricted  to  two  or  three  ar- 
ticles only,  but  for  the  reasons  given  in  discussing  the  force  value 
of  different  foods  (p.  6)  there  is  no  single  food,  not  even  milk, 
which  will  support  adult  man  in  optimum  health  and  vigor  for  long. 
There  are  many  primitive  races  and  tribes  of  man  who  live  comfort- 
ably upon  a  diet  so  restricted  that  it  would  soon  prove  unbearable 
for  a  European  or  an  American.  Much,  therefore,  depends  upon 
custom,  and  no  doubt  upon  heredity  and  race.  The  Hindu  eats 
boiled  rice  and  ghee,  or  melted  butter,  and  the  low-caste  Chinese 
eats  rice  to  the  almost,  but  not  complete,  exclusion  of  other  food; 
the  Eskimo  lives  upon  one  or  two  kinds  of  meat  or  fish,  and  a  little 
fat;  and  the  Congo  native  subsists  chiefly  upon  the  plantain.  The 
Central  American  Indian  lives  almost  entirely  upon  maize,  and  some 
of  the  Polynesians  eat  breadfruit  alone  for  two-thirds  of  the  year. 
The  roving  Indian  of  the  North  American  plains  originally  subsisted 
all  winter  upon  a  diet  of  salt  meat,  and  the  Scotch  peasants  formerly 
lived  for  six  days  in  the  week  mainly  upon  oatmeal  porridge. 

Such  a  monotony  of  diet  is,  however,  usually  a  question  of  en- 
vironment or  necessity  and  not  of  choice.  The  carnivorous  Eskimo 
enjoys  canned  vegetables  when  they  are  offered  to  him,  and  the  vege- 


372  FOOD  DIGESTION 

tarian  African  native  gorges  himself  with  meat  when  he  can  obtain 
it.  It  is  the  ability  to  subsist  upon  a  variety  of  foods  which  makes  it 
possible  for  man  to  adapt  himself  so  well  to  his  environment  when 
he  migrates  from  one  extreme  of  climate  to  another.  This  adapta- 
tion is  also  possible  because  the  elementary  foods  possess  general 
nutritive  properties  for  all  the  organs  of  the  body,  rather  than  spe- 
cial value  for  individual  structure;  for  example,  there  is  no  "brain 
food  "  in  distinction  from  food  which  nourishes  other  organs  as  well. 

An  ideally  perfect  food  combination  is  based  upon  purely  theo- 
retical considerations  of  the  needs  of  the  body,  for  just  so  much 
albumin,  fat,  starch,  sugar,  salts,  and  water  would  be  a  compound 
which  in  a  very  short  time  would  become  too  monotonous  to  be 
eaten.  Even  the  domestic  animals  are  kept  in  better  condition  by 
occasional  slight  changes  in  diet  —  such,  for  instance,  as  are  afforded 
by  change  of  pasturage  or  the  variety  which  the  season  of  the  year 
produces  in  their  natural  food;  and  it  is  well  known  that  the  flavor 
of  the  meat  of  fish  and  wild  animals  depends  upon  the  nature  of 
their  diet.  For  example,  canvasback  and  redhead  ducks  are  much 
more  palatable  while  feeding  upon  the  wild  celery  plant  than  when 
eating  other  food,  domestic  turkeys  and  capons  improve  when  fed 
upon  grain,  swine  flesh  is  made  better  by  feeding  the  animal  with 
corn  than  with  skimmed  milk,  and  salmon  and  shad  acquire  a  more 
delicate  flavor  when  feeding  in  fresh-water  rivers. 

In  a  report  of  digestion  experiments  made  for  the  U.  S.  Department 
of  Agriculture  by  Charles  D.  Woods  and  L.  H.  Merrill,  the  state- 
ment is  made  that  "  it  is  a  matter  of  common  observation  that  di- 
gestion experiments  made  with  one  kind  of  food  material  do  not 
give  on  the  whole  as  reliable  results  as  those  in  which  two  or  more 
food  materials  are  used.  In  other  words,  it  appears  that  with  a 
mixed  diet  the  same  person  will  digest  a  larger  proportion  of  nutrients 
than  with  a  diet  composed  of  a  single  food  material." 

Among  some  peoples  the  variety  of  food  is  considerably  restricted 
by  religious  observances,  custom,  and  associations.  For  instance, 
there  is  the  Buddhist  prohibition  of  meat  and  the  Jewish  prohibition 
of  swine  flesh.  When  a  variety  in  food  cannot  be  secured  the  de- 
sired effect  in  stimulating  the  appetite  and  digestive  secretions  may 
be  obtained  by  altering  the  methods  of  cooking  and  by  modifying 
the  taste  and  odor  of  food.  On  the  other  hand,  too  great  variety, 
as  well  as  too  elaborate  cooking,  becomes  equally  tiresome.  Those 
who  cat  constantly  at  restaurants  and  large  hotels,  where  the  table 
is  greatly  diversified,  often  find  that  a  change  to  a  simpler  home 
table  agrees  with  them  hotter. 


THE   NERVOUS  SYSTEM   AND   DIGESTION  373 

"Woodruff  attributes  the  decrease  in  drunkenness  in  the  past  few- 
years  in  the  United  States  army  to  the  advantages  accruing  from 
a  much  greater  variety  in  diet  since  fresh  vegetables  were  made  a 
part  of  the  ration,  and  since  by  a  system  of  exchange  the  soldier  has 
been  enabled  to  barter  an  excess  of  common  ration  food  for  a  few 
articles  of  luxury.  He  also  says :  "  Variety  is  necessary  in  the 
army  for  another  reason:  When  the  diet  is  very  simple  there  is  apt 
to  be  constipation,  and  in  the  field  this  condition  is  sometimes  quite 
marked.  It  is  recognized  by  physicians  that  chronic  constipation 
cannot  be  properly  treated  with  drugs,  and  it  must  be  rectified  by 
diet." 

THE  NERVOUS  SYSTEM  AND  DIGESTION 

The  influence  of  the  nervous  system  on  digestion  is  very  com- 
plex. In  a  general  way,  the  nerves  may  affect  the  digestive  process 
(a)  through  the  circulation,  (&)  through  motion,  (c)  through 
glandular  action.  The  nerves  chiefly  concerned  in  these  processes  are 
the  branches  of  the  sympathetic  system  and  the  vagus.  The  vagus, 
through  its  association  with  the  cardiac,  vasomotor,  and  respiratory 
centers  in  the  medulla  oblongata,  places  the  vital  functions  of  the 
body  in  very  intimate  connection  with  food  stimulation  acting  through 
the  branches  of  the  nerve  in  the  alimentary  canal. 

(a)  Action  through  the  Circulation. —  The  nerves  influence  diges- 
tion through  the  circulation  by  their  vasomotor  control,  regulating 
the  caliber  of  the  vessels  and  quantity  of  blood  supplied  to  the  walls 
of  the  alimentary  canal,  the  local  blood  pressure,  and  the  consequent 
rate  of  secretion  and  absorption. 

(&)  Action  through  Motion. —  The  nerves  influence  the  movements 
of  the  entire  alimentary  canal,  either  accelerating  or  inhibiting  them, 
thus  controlling  the  propulsion  of  the  food,  its  admixture  with  secre- 
tions, and  its  contact  with  absorbing  surfaces. 

(c)  Action  through  the  Glands. —  The  nerve  supply  of  the  diges- 
tive glands  is  distributed  to  their  blood  vessels,  and  also  probably  to 
some  extent  to  the  cells  of  the  gland  parenchyma.  This  latter  dis- 
tribution is  not  always  demonstrable  histologically  in  man,  but  the 
influence  is  unquestionable. 

Under  normal  conditions,  the  nerves  act  mainly  in  connection 
with  the  digestion  through  reflex  stimulation  produced  by  mechan- 
ical irritation  of  food  and  by  the  chemical  irritation  of  its  different 
ingredients  as  they  undergo  absorption.  But,  in  addition,  nerve  cur- 
rents from  the  central  nervous  system  (psychic  influences)  or  from 


374  FOOD  DIGESTION 

a  remote  peripheral  origin  may  interfere  with  the  normal  nerve 
functions.  Every  one  is  familiar  with  examples  of  acute  indigestion 
produced  by  fatigue  of  the  nervous  system,  undue  mental  excite- 
ment, emotion,  etc.  For  any  given  phase  of  digestion,  disturbance 
of  normal  nerve  function  will  retard  the  process  more  in  its  earlier 
stages  by  checking  or  altering  gland  secretion.  In  its  later  stages 
the  effect  of  the  nervous  system  will  be  more  pronounced  in  con- 
trolling or  inhibiting  absorption.  Overstimulation  of  the  local  nerves 
of  the  alimentary  tract  may  excite  an  increased  watery  secretion  and 
exaggerate  peristaltic  movement  of  the  intestines,  thereby  hastening 
the  passage  of  the  food  through  them  before  there  is  time  for  diges- 
tion or  absorption,  and  giving  rise  to  diarrhoea. 

CIRCULATION  AND  DIGESTION 

The  influence  of  the  circulatory  system  upon  digestion  appears 
in  the  composition  of  the  blood  and  in  its  rate  of  supply  to  the 
digestive  glands.  Vigorous  active  circulation  accompanies  good  di- 
gestion and  maintains  a  normal  local  reaction  and  temperature,  and 
feeble,  sluggish  circulation  produces  local  congestion  of  the  viscera 
and  interferes  with  gland  secretion  and  absorption.  The  salivary 
secretion  becomes  watery  and  contains  a  smaller  percentage  of  solids, 
after  stimulation  of  the  chorda  tympani,  and  when  the  sympathetic 
nerves  are  stimulated  exactly  the  reverse  occurs.  Hence  the  blood 
supply  is  shown  to  alter  the  digestive  power  of  a  secretion  by  modify- 
ing its  composition. 

Blood  which  is  watery,  anaemic,  or  deficient  in  proteid  ingredients, 
furnish  poor  materials  for  the  manufacture  of  the  digestive  se- 
cretions, and,  further,  the  muscular  walls  of  the  alimentary  canal 
suffer  from  malnutrition  and  peristaltic  action  is  diminished. 

TEMPERATURE  AND  DIGESTION 

Both  the  external  temperature  and  the  internal  body  heat  in- 
fluence digestive  processes.  The  effect  upon  the  system  of  the  tem- 
perature of  food  and  drink  is  also  a  matter  of  important  consideration. 

Hot  food  and  drinks  in  cold  weather,  cold  food  and  beverages 
in  hot  weather,  are  instinctively  resorted  to  by  almost  every  one, 
although  this  is,  no  doubt,  as  much  due  to  mental  association  and, 
perhaps,  a  temporary  agreeable  sensation  of  the  temperature  in 
swallowing  as  it  is  to  any  decided  influence  exerted  over  the  body 
temperature. 


TEMPERATURE  AND  DIGESTION  375 

Sudden  modifications  in  the  atmospheric  temperature  of  either  ex- 
cessive heat  or  cold  react  upon  the  circulation,  respiration,  and  the 
nervous  system  in  a  variety  of  ways  and  indirectly  affect  the  digestive 
apparatus.  The  shock  of  sudden  or,  more  particularly,  of  con- 
tinued exposure  to  cold  over  the  entire  surface  of  the  body  tends 
to  constrict  the  peripheral  blood  vessels  and  produce  congestion  of 
the  visceral  vessels,  modifying  secretion  and  absorption  in  conse- 
quence. A  local  application  of  heat  and  of  cold  over  the  abdominal 
wall  during  activity  of  the  digestive  organs  has  limited  influence. 
Patients  wearing  a  Leiter  coil  over  the  abdomen  through  which  ice 
water  is  continually  passed  for  many  hours  do  not  necessarily  suffer 
from  retarded  digestion,  nor  do  those  who  are  having  poultices  con- 
tinuously applied  to  the  abdomen.  In  a  series  of  experiments  which 
I  made  to  determine  the  extent  of  heat  penetration  through  the 
abdominal  wall  ("  Local  Thermotherapy,"  X.  Y.  Medical  Record, 
April  13,  1907)  it  was  shown  that  the  application  of  heat  or  of  cold 
of  such  extremes  as  may  be  borne  without  discomfort  has  little  or  no 
influence  on  the  circulation  in  the  stomach  or  the  intestines  or 
upon  the  temperature  of  those  organs  so  long  as  the  subcutaneous 
circulation  is  vigorous.  This  is  owing  to  the  rapid  neutralization 
of  the  heat  or  cold  applied  externally  by  the  constantly  changing 
layer  of  blood  flowing  beneath  the  surface.  In  anaesthetized  dogs, 
a  poultice  of  140°  F.  or  an  ice  coil  with  water  at  34°  F.  placed 
over  one  side  of  the  abdominal  wall  does  not  raise  the  temperature 
of  a  long-stemmed  thermometer  more  than  a  quarter  of  a  degree 
when  slipped  beneath  the  abdominal  wall  through  a  perforation  or 
held  immediately  below  the  poultice  or  coil.  If,  however,  the  animal 
be  killed,  circulation  ceases,  and  the  temperature  of  the  thermometer 
will  immediately  be  affected  to  the  extent  of  fifteen  or  twenty  de- 
grees. It  is  doubtful,  therefore,  whether  enfeebled  digestion  can 
be  much  influenced  by  the  local  application  of  warmth  over  the  ab- 
dominal wall.  Many  persons,  however,  who  have  a  tendency  to  in- 
testinal indigestion  find  it  both  agreeable  and  salutary  to  wear 
continuously  a  broad  flannel  bandage  about  the  abdomen  to  favor 
uniformity  in  temperature  and  prevent  the  liability  of  taking  cold. 

The  variations  of  body  temperature  between  the  highest  fever  and 
the  lowest  depression  do.  not  exceed  the  limits  of  temperature  at 
which  digestion  is  known  to  proceed  when  artificially  conducted,  so 
that  such  variations  do  not  of  themselves  alone  destroy  digestive 
power  in  the  stomach.  The  latter  is  usually  diminished  or  lost 
during  fever,  but  this  is  owing  more  to  disturbances  of  the  circulatory 
and  nervous  svstems  than  to  increased  warmth  of  the  stomach. 


376  FOOD  DIGESTION 

Efforts  to  raise  or  lower  the  local  temperature  in  the  stomach 
during  digestion  by  swallowing,  respectively,  hot  water  or  pounded 
ice  are  not  productive  of  very  striking  results,  as  may  be  determined 
in  a  patient  having  a  gastric  fistula,  or  by  means  of  the  cesophageal 
tube.  Nevertheless,  it  is  customary,  and  no  doubt  best,  to  administer 
stimulants  hot  in  collapse  from  any  cause. 

Wunderlich,  Fothergill,  and  others  have  laid  considerable  stress 
upon  the  antipyretic  value  of  giving  all  fluids  very  cold  in  fevers, 
but  I  have  yet  to  see  any  effect  upon  genuine  pyrexia,  as,  for  ex- 
ample, in  typhoid  fever,  depending  upon  whether  milk  or  other  fluids 
were  administered  very  hot  or  iced.  I  often  prescribe  hot  boiled 
milk  in  such  cases  if  patients  prefer  it,  because  the  quantity  of  heat 
units  which  may  thus  be  conveyed  into  the  body  is  too  small  to  merit 
serious  consideration. 

It  is  a  popular  belief  that  rich  wines  and  oils  are  "heating" 
foods,  and,  conversely,  "  cooling  drinks "  have  long  been  used  in 
fevers,  but  the  use  of  iced  fluids  and  of  cracked  ice  itself  for  relief 
of  thirst  in  fevers  is  of  comparatively  recent  date. 

Hot  fluids  drunk  favor  perspiration,  and  sometimes  aid  expectora- 
tion, but  this  is  because  they  are  promptly  absorbed  and  added  to 
the  volume  of  the  blood,  not  because  they  contribute  many  heat 
units  to  the  body.  Winternitz  endeavored  to  show  by  sphygmograms 
that  the  imbibition  of  cold  fluids  increases  arterial  tension,  and  that 
of  hot  fluids  lessens  it.  This  may  be  true,  but  the  sphygmograph 
is  not  at  all  a  reliable  instrument,  and  certainly  the  clinical  ap- 
plication of  this  rule  is  not  capable  of  substantiation,  although  in 
giving  hot-air  baths  to  promote  perspiration  in  Bright's  disease  hot 
drinks  are  of  undoubted  service. 

With  practice  one  may  learn  to  swallow  water  which  is  uncom- 
fortably hot  to  the  touch  —  at  a  temperature  of  115°  or  120°  F. 

The  drinking  of  very  hot  water  before  meals  aids  in  cleansing 
the  mucous  membrane  in  cases  of  gastric  catarrh  and  acts  as  a 
diuretic.  The  rate  of  local  digestion  in  the  stomach  is  comparatively 
little  influenced  by  swallowing  either  hot  fluids,  such  as  soups  or 
broths,  or  hot  solid  foods,  and  similarly  it  is  not  much  retarded  by 
taking  such  substances  very  cold,  provided  in  each  case  they  are  swal- 
lowed very  slowly.  Some  food  is  more  digestible  when  eaten  hot 
than  cold,  but  with  other  food  the  reverse  is  true.  In  either  case 
it  is  not  so  much  because  of  the  warming  or  cooling  of  the  stomach, 
but  because  of  the  physical  condition  of  the  food.  For  example, 
some  person?  who  cannot  digest  hot  mutton  fat  can  take  it  cold  be- 
cause it  becomes  friable  and  mixes  better  with  other  food.  Some  per- 


TEMPERATURE  AND  DIGESTION"  377 

sons  with  very  sensitive  stomachs  cannot  take  the  fat  of  cold  butter 
spread  upon  bread,  but  can  digest  it  if  melted  thoroughly  into  hot 
toast,  which  subdivides  the  fat  particles  and  keeps  them  from  fusion. 
Hot  boiled  ham  is  more  indigestible  than  cold  ham  for  many  persons. 
Hot  milk  may  be  more  digestible  for  invalids  than  iced  milk,  yet 
the  latter  may  be  better  borne  if  vomiting  be  present.  Much  depends 
upon  habit  and  individual  peculiarities.  One  may  begin  a  dinner 
with  iced  raw  oysters,  then  take  hot  soup,  and  later  conclude  the 
meal  with  ice  cream,  followed  by  hot  coffee,  and  yet  throughout,  the 
temperature  of  the  stomach  contents  does  not  vary  so  much  as  half 
a  degree,  because  the  warm  blood  circulating  so  rapidly  and  abun- 
dantly within  its  walls  and  those  of  the  oesophagus  maintains  the 
necessary  normal  average  most  favorable  to  digestion.  Hot  food  is 
cooled  and  cold  food  is  warmed  in  swallowing,  and  it  may  be 
said  the  hotter  or  the  colder  it  is,  the  less  likely  it  is  to  modify 
the  rate  of  gastric  digestion,  for  these  extremes  of  temperature  neces- 
sitate slow  swallowing.  Swallowing  several  tumblerfuls  of  iced  wa- 
ter in  quick  succession  does  cool  the  stomach  and  inhibit  digestion 
by  local  reduction  of  temperature,  and  also  by  shock  to  the  gastric 
nerves;  but  this  effect  is  less  than  is  commonly  supposed.  There  are 
about  fourteen  pounds  of  blood  in  the  body,  having  an  average  tem- 
perature of  very  nearly  100°  K,  all  of  which  in  turn  keeps  cir- 
culating through  the  digestive  organs,  and  a  single  tumblerful  of 
iced  water  poured  into  such  a  volume  of  warm  fluid  would  not  lower 
the  temperature  of  the  whole  very  much.  This  is  why  swallowing 
pounded  ice  is  of  so  little  avail  to  control  gastric  hemorrhage,  much 
less  pulmonary  hemorrhage,  although  it  may  relieve  nausea  some- 
what. In  support  of  these  statements  are  the  results  of  many  ex- 
periments which  I  have  made  upon  patients  undergoing  treatment 
by  lavage,  to  whom  I  have  given  fluids  at  different  temperatures, 
which  were  immediately  siphoned  out  of  the  stomach,  and  tested  for 
heat  loss  or  gain.  ("  Local  Thermotherapy,"  N.  Y.  Medical  Eecord, 
April  13,  1907.)  Two  tumblerfuls  of  ice  water  may  be  swallowed 
slowly,  and  if  siphoned  out  again  in  five  minutes  the  temperature 
of  the  fluid  will  be  found  to  have  risen  to  fully  95°  F. 

The  question  often  has  been  raised  as  to  whether  the  body  tem- 
perature can  be  affected  permanently  by  alterations  in  the  quality 
of  the  diet.  It  may  be  stated  definitely  that  so  long  as  the  diet  is 
abundant  and  nutritious  it  makes  no  difference  whether  man  is  car- 
nivorous., a  vegetarian,  or  lives  upon  mixed  diet.  Insufficient  food 
and  starvation  or  inanition  from  improper  food,  it  is  well  known, 
reduce  the  body  temperature  to  from  one  to  three  or  more  degrees 


378  FOOD  DIGESTION 

below  normal,  but  this  is  mainly  due  to  the  enfeebled  circulation 
and  lessened  rate  of  general  metabolism.  Excess  of  alcohol  also  re- 
duces body  temperature  slightly. 

Improper  and  indigestible  food  may  cause  temporary  rise  in  tem- 
perature, but  this  is  usually  caused  by  more  or  less  gastritis  or 
gastroenteritis,  and  is  therefore  independent  of  normal  considera- 
tions. The  total  daily  variation  in  body  temperature  normally  pro- 
duced by  the  ingestion  of  food  does  not  commonly  exceed  %°  F., 
but  it  may  reach  1°  F.  The  vegetarian  rabbit  has  as  high  a  tem- 
perature as  a  dog  fed  upon  animal  food  alone.  The  grass-eating 
cow  has  a  temperature  three  degrees  above  man's  and  quite  equal 
to  that  of  many  strictly  carnivorous  animals.  The  graminivorous 
pigeon  has  a  temperature  as  high  as  that  of  the  fish-eating  gull. 
N"o  deductions  can  therefore  be  made  in  regard  to  any  permanent 
influence  of  diet  upon  normal  body  temperature  in  healthy  animals 
or  in  man. 

The  loss  of  body  heat  consequent  upon  Starvation  and  Inanition  is 
further  discussed  under  those  headings  (p.  347). 

EXERCISE  AND  DIGESTION 

The  influence  of  muscular  exercise  upon  digestion  is  practically 
exemplified  by  every  one's  personal  experience.  Violent  exercise,  even 
by  those  of  robust  constitution,  taken  immediately  after  the  ingestion 
of  food  almost  invariably  retards  the  process  if  it  does  not  produce 
acute  dyspeptic  symptoms,  and  perhaps  vomiting.  This  is  due  mainly 
to  the  modification  in  the  distribution  of  the  blood,  which  during 
active  exercise  passes  in  large  amount  to  the  periphery  of  the  body, 
and  in  much  less  quantity  to  the  abdominal  organs.  There  are  also 
increased  products  of  waste  matter  formed  during  muscular  activity 
which  circulate  in  the  blood,  and  it  is  possible,  though  it  cannot 
be  asserted  definitely,  that  they  may  interfere  temporarily  with  the 
digestive  secretions.  Young  children  between  the  ages  of  four  or 
five  and  ten  or  twelve  suffer  much  less  from  the  influence  upon  di- 
gestion of  violent  exercise  than  do  adults.  It  is  a  common  experience 
to  see  children  romping  and  playing  violent  games  immediately  after 
eating  without  necessarily  provoking  indigestion  —  a  habit  which 
would  be  very  disastrous  to  adults.  On  the  other  hand,  exercise  has 
a  very  important  relation  to  digestion  when  taken  at  proper  times 
and  in  right  degree.  This  influence  is  to  be  attributed  rather  to  the 
combined  effect  upon  the  circulation  and  respiration  and  general 
functional  activity  of  the  tissues  which  promotes  their  nutrition  than 


EXERCISE   AND  DIGESTION  379 

to  any  special  local  action  on  the  stomach  or  intestines.  Exercise 
of  a  certain  kind  compresses  or  shakes  the  liver  in  such  a  manner  as 
to  favor  the  elimination  of  bile  from  it  and  increase  its  functional 
activity.  For  this  reason  horseback  riding  is  the  most  useful  form 
of  exercise  for  many  varieties  of  dyspepsia  and  so-called  "  bilious- 
ness/' 

Moderate  exercise  often  may  be  taken  advantageously  in  the  morn- 
ing on  rising  for  ten  or  fifteen  minutes  in  order  to  produce  good 
perspiration  before  taking  a  cold  bath.  Such  exercise  with  dumb- 
bells, Indian  clubs,  or  weights  with  pulleys  does  not  harm  the  ap- 
petite, and  for  some  persons  it  is  invigorating  and  beneficial. 
Stronger  exercise,  such  as  bicycle  riding  or  taking  long  walks  before 
breakfast,  is  not  to  be  recommended  unless  the  individual  has  been 
greatly  overfed  the  night  before.  In  the  early  morning  hours,  with 
an  empty  stomach,  exposure  to  the  influence  of  cold  and  damp,  or 
possibly  to  infectious  diseases,  is  believed  to  be  greater  than  at  other 
hours  in  the  day.  Physicians  visiting  cases  of  infectious  diseases 
do  well  to  go  only  at  a  time  of  day  when  they  have  recently  taken 
a  full  meal  and  when  they  are  not  suffering  from  extreme  fatigue. 

Men  differ  greatly  in  the  amount  of  exercise  which  they  find 
necessary  to  maintain  good  health  and  a  normal  appetite.  To  keep 
a  really  vigorous  man  in  the  best  bodily  condition  he  should  take 
daily  exercise  amounting  to  one  hundred  and  fifty  foot  tons  of  work, 
or  an  equivalent  of  a  walk  on  a  level  of  about  nine  miles;  but  very 
few  are  able  to  accomplish  this  excepting  day  laborers. 

The  influence  of  food  upon  muscular  activity  has  been  studied 
by  Hodge,  who  constructed  a  movable  cage  so  arranged  that  any 
movements  of  the  animal  which  it  contains  are  communicated  to 
the  cage  itself,  and  through  it  to  a  recording  tambour  and  kymo- 
graphion.  In  this  manner  the  restless  activity  of  the  hungry  animal 
seeking  for  food  about  its  cage  is  recorded,  as  well  as  the  indolence 
produced  by  a  satisfying  fatty  diet  and  the  stimulating  effect  of 
nitrogenous  food.  For  example,  he  demonstrated  that  a  mouse  well 
fed  on  cornmeal  alone  may  be  active  but  a  few  minutes  in  the  day, 
whereas  the  same  animal  fed  upon  meat  and  cream  alone  will  exer- 
cise for  ten  hours  out  of  the  twenty-four.  This  is  no  doubt  due  to 
combined  effects  of  the  influence  of  the  feeling  of  satiety,  exhilaration, 
varying  functional  activity  of  different  organs  of  digestion,  and  of  the 
circulation  and  nervous  system.  It  is  to  be  hoped  that  future  in- 
vestigations will  differentiate  more  clearly  between  these  factors. 


380  FOOD  DIGESTION 


The  custom  of  spending  half  an  hour  in  making  a  leisurely  toilet 
for  dinner  is  beneficial  in  giving  the  rest  to  mind  and  body  whigh 
puts  the  latter  into  the  most  favorable  conditions.  Dyspeptics  and 
persons  subject  to  an  irritable  or  feeble  digestive  system  may  derive 
much  benefit  by  observing  the  rule  of  not  eating  when  suffering 
from  bodily  or  mental  fatigue.  They  should  lie  down  from  half 
an  hour  to  one  hour  and  quietly  rest  before  each  meal,  which  may 
then  be  digested  in  comfort.  Muscular  fatigue  and  overexertion 
demand  food  for  the  replenishment  of  waste  material,  but  the  im- 
mediate digestive  process  is  much  facilitated  by  an  intervening  period 
of  rest.  It  is  often  advisable  for  them  to  rest  (but  not  sleep) 
for  a  similar  time  after  meals.  The  practice  of  sipping  hot  coffee 
after  dinner  and  of  smoking  a  cigar  is  conducive  to  the  rest  which 
should  be  taken,  whenever  possible,  after  the  ingestion  of  a  heavy 
meal. 

Sleep  in  Relation  to  Meals. —  Sleep  is  often  affected  by  the  quan- 
tity of  food  taken.  Overeating,  with  lack  of  physical  exercise  com- 
bined with  sedentary  habits  and  brain  work,  is  very  likely  to  induce 
drowsiness. 

During  profound  sleep  the  functions  of  the  body  are  all  more 
or  less  reduced  in  activity,  and  the  motility  of  the  stomach  is  less- 
ened. The  rate  of  circulation  and  respiration  becomes  slower,  and 
gland  secretion  and  digestive  processes  are  retarded.  For  this  reason, 
after  eating  a  heavy  meal  at  night,  it  is  unwise  to  retire  for  two  or 
three  hours  until  the  period  of  gastric  digestion  is  in  part  com- 
pleted. It  is  true  that  many  of  the  lower  animals,  particularly  the 
carnivores,  are  accustomed  to  lie  down  and  sleep  immediately  after 
taking  their  food,  but  their  functions  in  so  many  ways  differ  from 
those  of  man  that  little  is  to  be  gained  by  a  comparison  with 
them,  and  their  sleep  is  usually  light  until  digestion  is  accomplished. 
On  the  other  hand,  in  man,  if  profound  sleep  follows  eating  of  a 
heavy  meal,  digestion  is  very  apt  to  be  disturbed.  A  large  volume 
of  blood  is  kept  in  the  abdominal  vessels  during  digestion,  and  the 
cerebral  circulation  is  modified  in  consequence.  It  is  possible  also 
that  the  various  products  of  nutrition  which  are  being  absorbed 
into  the  blood  may  act  in  stimulating  the  central  nervous  system 
in  peculiar  ways.  Such  sleep  is  restless,  and  is  disturbed  by  dreams 
and  nightmares,  and  one  awakes  fatigued. 

Persons  whose  health  is  below  the  average  on  account  of  disor- 
ders of  digestion  and  assimilation  not  infrequently  find  that  they 


REST   AND   SLEEP  AND   DIGESTION  381 

become  very  sleepy  after  eating,  more  particularly  after  eating  a 
heavy  meal  at  noon;  this  condition  is  sometimes  very  annoying,  and 
always  indicates  a  lack  of  balance  between  the  income  and  output 
of  energy,  which  should  be  regulated  by  proper  attention  to  diet  and 
exercise.  Usually  in  such  cases  the  difficulty  consists  in  habitually 
eating  more  food  than  the  system  can  appropriate,  and  cleansing 
the  body  through  the  emunctories,  whereas  a  temporary  reduction  in 
the  quantity  of  food  eaten,  will  remove  it.  In  other  cases  the  trouble 
arises  from  the  exhaustion  of  the  nervous  system,  which  is  unable 
properly  to  conduct  two  functions  at  once  —  that  is,  to  regulate  diges- 
tion and  at  the  same  time  exercise  the  mind.  Obviously,  in  such 
cases,  rest  and  tonic  treatment  are  indicated.  Food  should  be  given 
more  often,  but  in  small  quantity. 

In  England  the  custom  is  prevalent  among  some  classes  outside 
of  the  larger m  cities  of  taking  four  meals  a  day.  A  breakfast  at 
about  eight  o'clock  and  dinner  from  one  to  two,  and  a  heavy  tea  — 
that  is,  a  lunch  with  tea  and  some  solid  food  —  between  five  and 
six,  which  is  followed  by  supper  from  eight  to  nine.  This  practice 
is  well  adapted  for  some  persons,  especially  young,  growing  children 
at  school  (see  Diet  in  Schools),  but  older  children  are  apt  to  overeat 
if  they  follow  such  a  custom.  An  interval  of  from  one  and  a  half 
to  two  hours  should  elapse  between  eating  supper  and  retiring,  and 
from  two  to  three  hours  between  dinner  and  bedtime. 

If  the  alimentary  canal  is  too  empty  sleep  will  be  retarded,  and 
the  earlier  stages  of  hunger,  before  great  exhaustion  has  occurred, 
may  be  accompanied  by  restlessness  and  insomnia.  A  very  little 
food  taken  into  the  stomach  under  these  conditions  will  often  pro- 
duce sleep  promptly.  The  aged,  whose  systems  are  susceptible  to 
slight  changes  in  their  condition  or  environment,  are  liable  to  be- 
come sleepy  after  their  meals,  and  they  find  it  to  their  advantage  to 
take  a  brief  nap  after  dinner;  but  this  sleep  is  not  usually  pro- 
found, and  if  it  is  too  prolonged  it  indicates  exhaustion,  which 
should  be  met  by  more  careful  attention  to  diet  and  stimulation. 

Starvation  may  cause  persistent  insomnia.  Eetiring  late  without 
dinner  or  supper  results  in  restlessness  and  insomnia,  which  may 
often  be  cured  by  taking  a  glass  of  hot  milk,  or  a  cup  of  chocolate 
and  some  light  farinaceous  article,  or  a  light  sandwich  and  a  glass 
of  beer.  In  all  ordinary  cases  of  insomnia  it  is  well  to  see  what 
help  may  be  got  from  diet  and  regular  habits  before  resorting  to 
hypnotics.  (See  Insomnia.) 

In  some  diseases  it  becomes  a  grave  question  between  nourish- 
ment and  sleep  as  to  which  is  the  more  important.  Sleep  often  is 


382  FOOD  DIGESTION 

more  needful  than  food,  and  it  is  the  duty  of  the  physician  to  see 
that  there  is  a  proper  balance  between  them.  In  general,  in  ex- 
hausting disease,  protracted  typhoid  or  other  fevers,  etc.,  nourishment 
should  be  given  once  in  two  hours  by  day,  but  once  in  three  or  four 
hours  by  night.  In  cases  in  which  the  patient  does  not  readily  sleep 
again  after  being  aroused  for  food  it  is  well  to  relax  the  rule,  and 
give  the  patient  a  good  night's  rest  of  five  or  six  hours  without 
awakening  him  for  food;  but  the  degree  of  exhaustion  and  need  of 
cardiac  stimulants  should  be  the  guide  in  each  separate  case. 

MENTAL  EMOTION  AND  DIGESTION 

Strong  mental  emotion,  such  as  fright,  terror,  or  excessive  ex- 
citement of  almost  any  kind,  inhibits  the  digestive  functions,  espe- 
cially in  the  stomach,  but  also  in  the  intestines.  Such,  emotion  may 
be  accompanied  by  vascular  disturbances  which  will  react  upon  the 
digestive  organs,  and  in  addition  there  seems  to  be  a  diversion  of 
nerve  currents  from  their  proper  course.  Pleasurable  emotions,  how- 
ever, affect  digestion  favorably,  and  the  expression  "  laugh  and  grow 
fat"  is  certainly  not  without  physiological  basis. 

Huf eland  wrote  that  "  laughter  is  one  of  the  greatest  helps  to 
digestion  with  which  I  am  acquainted,  and  the  custom  prevalent 
among  our  forefathers  of  exciting  it  at  table  by  jesters  and  buffoons 
was  founded  upon  true  medical  principles."  By  compression  of  the 
stomach  under  the  movements  of  the  diaphragm  in  laughter,  the  food 
currents  are  accelerated. 

Prolonged  anxiety  and  worry,  in  almost  every  instance,  result  in 
more  or  less  gastric  indigestion  and  malassimilation,  so  that,  although 
the  appetite  may  remain  good,  nervous  dyspepsia,  constipation,  and 
loss  of  weight  result. 

FOOD  IN  THE  MOUTH 

In  patients  who  are  unable  from  weakness  or  the  prostration  of 
fever,  to  take  solid  food  or  to  cleanse  the  mouth  themselves,  lack  of 
movement  in  the  tongue  and  buccal  muscles  prevents  proper  cleansing 
of  the  teeth,  and  particles  of  food  accumulate  about  the  gums.  In 
extreme  weakness  of  the  facial  muscles  the  jaw  drops  and  mouth 
breathing  results.  The  air  passing  through  the  mouth  evaporates  the 
moisture  present  and  gives  rise  to  dryness  of  the  tongue,  which  may 
become  so  extreme  as  to  interfere  with  deglutition  and  articulation. 

In  such  cases  the  mouth  should  be  moistened  frequently  by  the 


FOOD  IN   THE   MOUTH  383 

nurse  and  swabbed  out  by  some  antiseptic,  such  as  a  saturated  solu- 
tion of  boric  acid  or  diluted  Listerine.  This  topic  will  be  more  fully 
treated  under  the  heading  Dietetic  Treatment  of  Typhoid  Fever, 
p.  474. 

Food  which  is  allowed  to  collect  in  the  cavities  of  decayed  teeth 
favors  the  development  of  bacteria,  which  on  being  swallowed  may 
become  a  cause  of  dyspepsia  by  exciting  malfermentation  in  the  stom- 
ach, especially  of  milk.  Much  bacterial  filth  accumulates  beneath 
artificial  teeth  which  are  not  frequently  cleansed. 

Imperfect  or  painful  teeth,  or  swollen  gums,  interfere  with  the 
proper  mastication  of  food,  and  when  such  conditions  are  present 
care  should  be  exercised  that  all  food  eaten  be  soft  and  bland.  This 
applies  particularly  to  young  children,  very  old  persons,  and  the  in- 
sane, who  are  incompetent  to  take  care  of  their  own  mouths.  Young 
children  sometimes  appear  to  have  lost  appetite,  whereas  the  difficulty 
exists  in  soreness  of  the  mouth. 

The  digestion  of  carbohydrate  food  begins  in  the  mouth,  and  de- 
pends upon  the  activity  of  the  salivary  ferment  ptyalin,  which  converts 
starches  into  dextrin  and  maltose.  In  health  this  action  is  prompt 
and  vigorous,  and  much  of  the  starchy  food  is  digested  in  the  mouth, 
in  its  transit  along  the  cesophagus,  and  also  in  the  stomach,  until  the 
gastric  juice  becomes  so  acid  as  to  check  the  process,  for  ptyalin  is 
most  active  upon  the  alkaline  side  of  the  neutral  point,  and  strong 
acidity  inhibits  its  power.  Chittenden  has  demonstrated  that  after 
neutralizing  saliva,  ptyalin  fermentation  proceeds  well  in  the  presence 
of  0.005  per  cent  of  hydrochloric  acid,  but  stops  with  0.025  per  cent. 
Dufresne  is  responsible  for  the  statement  that  ptyalin  recovers  its 
activity  in  the  alkaline  intestine,  and  that  diastase  is  completely  de- 
stroyed by  the  gastric  juice. 

In  feeble  and  ill-nourished  persons  the  salivary  digestion  becomes 
much  impaired,  and  consequently  their  farinaceous  food  should  be 
partially  dextrinized  artificially  by  diastase  or  by  prolonged  cooking. 

An  acid  reaction  in  the  mouth  may  be  present  because  of  fer- 
mentation, not  because  the  saliva  itself  is  acid.  In  rheumatism  the 
saliva  is  very  often  acid.  This  reaction  causes  a  sensation  of  dry- 
ness,  lessens  the  taste  for  food,  and  gives  rise  to  thirst.  Saliva  which 
is  rich  in  cells  and  mucus  is  too  viscid,  and  does  not  moisten  the 
food  properly  during  mastication.  When  salivation  is  present  the 
ptyalin  becomes  too  dilute  to  have  any  digestive  action  upon  starchy 
foods.  If  swallowed,  the  too  abundant  saliva  carries  much  air  into 
the  stomach ;  and  if  it  is  alkaline,  it  neutralizes  the  gastric  juice.  A 
dry  diet  (see  Dry  Diet)  improves  this  condition. 


384  FOOD  DIGESTION 

Too  rapid  eating,  or  tachyphagia,  without  thorough  mastication,  is 
a,  very  common  fault,  and  from  time  to  time  apostles  of  deliberate 
mastication  or  bradyphagia  have  attained  notoriety  by  magnifying 
its  desirability  as  a  means  of  prolonging  life.  Among  the  latest  of 
these  is  Horace  Fletcher,  whose  work,  "  The  A.  B.  Z.  of  Our  Own 
Nutrition,"  is  largely  devoted  to  this  topic,  so  that  slow  eating  has 
heen  described  as  "  Fletcherism."  Fletcher's  theory,  as  practiced  for 
many  years  by  himself,  involves  two  principles ;  first,  to  masticate 
all  food  until  it  no  longer  tastes  agreeably,  before  swallowing;  and 
second,  to  follow  instinct;  i,  e.,  desire  in  the  choice  of  food  —  not  to 
eat  unless  hungry,  even  if  a  meal  be  omitted  occasionally,  and  to  se- 
lect such  foods  as  one  naturally  craves,  irrespective  of  habit,  con- 
ventionality or  preconceived  theory.  It  is  not  intended  to  count  the 
number  of  "  chews  "  given  each  mouthful  (like  Mr.  Gladstone,  who 
was  said  to  have  chewed  each  morsel  thirty-six  times),  nor  to  make 
eating  a  bore,  but  merely  while  eating  to  direct  attention  to  the 
pleasurable  sensation  of  taste  in  the  mouth,  as  long  as  it  lasts. 

Pawlow,  of  St.  Petersburg,  has  demonstrated  experimentally,  that 
the  flow  of  gastric  juice  is  stimulated  by  such  enjoyment  of  food, 
apart  from  the  *  advantage  which  thorough  mastication  possesses  in 
insalivating,  giving  time  for  copious  salivary  and  gastric  secretion  to 
form,  and  in  mascerating  and  mixing  the  food  particles.  On  the 
other  hand,  it  may  be  possible  to  overdo  mastication  and  prevent  the 
mechanical  stimulus  to  digestion  which  is  undoubtedly  afforded  by 
coarser  food  in  the  stomach.  Benedict  and  Milner  state  that : 

"  It  would  also  appear  that  when  the  common  food  materials  make 
Tip  the  diet  in  proportions  in  which  they  are  ordinarily  used,  in 
general  at  least  95  to  96  per  cent  of  the  total  organic  matter  is 
digested  and  utilized  by  the  body.  With  such  an  average  efficiency 
there  is  little  opportunity  for  improvement  in  the  thoroughness  of 
digestion  of  the  ordinary  diet.  Any  dietetic  practice,  therefore,  such 
as  excessive  mastication,  which  may  be  claimed  to  result  in  greater 
economy  in  the  utilization  of  food  so  far  as  it  relates  to  thoroughness 
of  digestion,  must  improve  upon  a  condition  in  which  there  is  already 
almost  complete  utilization." 

Fletcher  further  claims  that  his  method  of  eating  leads  naturally 
to  a  selection  of  a  smaller  proteid  ration,  which  is  an  advantage.  His 
system  has  received  recent  support  from  Prof.  Irving  Fisher  of  Yale, 
who  conducted  a  series  of  experiments  upon  nine  students. 

The  experiments  were  in  two  groups  of  ten  weeks  each  and  "  en- 
durance tests  "  were  made  three  times,  i.  e.,  at  the  beginning,  middle 
and  end  of  the  periods.  The  endurance  tests  comprised  running,  lift- 


FOOD   IX   THE   MOUTH  385 

ing  heavy  dumbbells  repeatedly,  holding  the  arms  or  legs  in  positions 
of  unwonted  exertion,  etc.  The  men  practiced  "  Fletcherism,"  and 
Fisher  added  a  third  rule,  "  when  instinct  is  in  doubt,  use  reason," 
i.  e.,  if  one  was  in  doubt  as  to  which  food  to  choose,  that  having 
a  known  low  proteid  content  was  to  be  selected.  A  liberal 
mixed  diet  was  allowed.  At  the  close  of  the  experiments,  it 
was  found  that  the  men  were  eating  much  less  proteid  than 
at  the  beginning,  and  that  they  lost  weight  and  strength,  but 
gained  in  endurance,  i.  e.,  single  muscular  feats  of  strength  were 
less  well  performed,  but  muscular  exertion  could  be  performed  longer, 
with  less  resulting  fatigue  or  exhaustion.  Whether  or  not  it  is  an 
advantage  for  the  average  man  to  go  on  losing  weight  and  strength 
for  the  sake  of  gain  in  endurance,  is  a  question  which  may  be  deter- 
mined properly  only  for  the  individual  subject. 

In  another  series  of  experiments  upon  49  persons  (Yale  Med.  Jrn., 
March,  1907),  Fisher  found  further  confirmation  of  his  theory  that  a 
low  proteid  diet  is  conducive  to  endurance,  but  his  results  as  reported 
show  much  variation.  Some  of  his  subjects  could  perform  one  en- 
durance test  best,  others  another  (deep  knee-bending,  holding  the 
arms  raised  for  long  periods,  etc.),  and  others  failed  to  show  uniform 
results  in  their  own  endurance. 

In  direct  opposition  to  these  dietetic  theories  of  Fletcher  and  Fisher 
are  many  scientific  experiments,  and  many  well-known  facts.  For 
instance,  the  health  and  certainly  the  endurance  of  the  entire  Japa- 
nese army  and  navy  has  increased  many  fold  since  there  has  been  a 
more  liberal  proteid  allowance  in  the  ration.  No  better  example  of 
endurance  can  be  cited  than  the  Japanese  coolie  runner,  who  easily 
covers  20  to  30  miles  a  day  with  his  carriage,  and  as  much  as  45 
miles  has  been  run  by  one  in  less  than  nine  hours.  Kintaro  Oshina, 
who  made  a  special  study  of  this  topic  at  the  Agricultural  Experi- 
mental Station  in  Sapporo,  Japan,  found  the  average  protein  in  the 
diet  of  such  a  man  to  be  above  40  per  cent.  This  authority  says : 

"  Contrary  to  the  public  belief,  it  is  the  general  impression  of  close 
observers  that  these  jinrikisha  men  commonly  spend  a  comparatively 
large  part  of  their  income  on  animal  food.  According  to  the  obser- 
vations of  Tiegel  the  jinrikisha  men  eat  a  large  amount  of  rice  during 
their  working  periods,  taking  meals  every  two  or  three  hours,  but 
during  the  period  of  rest  they  eat  considerable  quantities  of  fish,  eggs, 
beef,  and  pork.  With  regard  to  the  opinions  concerning  the  small 
amount  of  protein  in  the  diet  of  these  people,  he  believes  that  the  con- 
dition has  been  considerably  misrepresented."  Gardiner  (British 
Med.  Jour.,  1901,  p.  1010)  writes:  "  During  their  period  of  rest  they 
-  27 


386  FOOD  DIGESTION 

(jinrikisha  runners)  consume  large  quantities  of  meat  in  order  to 
build  up  strong  muscles,  but  while  actually  working  they  subsist 
mainly  on  rice." 

The  lifelong  habits  of  a  particular  race,  or  large  group  of  men,  are 
more  convincing  than  a  small  series  of  experiments  in  which  for 
periods  of  a  few  days  or  weeks,  selected  men  are  made  temporarily  to 
change  their  dietetic  habits.  The  Eskimo  is  another  large  proteid 
eater,  whose  phenomenal  feats  of  endurance  in  his  coast  voyages  and 
prolonged  inland  marches  often  have  been  recited  by  arctic  explorers. 

Directing  persons  to  follow  "  instinct "  in  their  appetite  is  as  grave 
an  error  as  to  urge  everyone  to  follow  the  same  dietetic  fad.  It 
surely  would  work  havoc  with  young  children,  as  much  as  it  would 
with  domestic  animals.  Craving  for  special  foods  is  easily  acquired, 
and  if  yielded  to  as  a  principle  would  frequently  result  in  dyspepsia 
and  biliousness  if  not  more  serious  digestive  disorders.  (See  Slow 
Eating  in  Dyspepsia,  p.  571.) 

FOOD  IN  THE  STOMACH 

Much  controversy  has  arisen  over  the  question  as  to  how  far  the 
stomach  performs  the  essential  work  of  digestion,  and  how  far  the 
intestine  is  responsible  for  it.  Some  writers  argue  that  the  stomach 
is  a  comparatively  useless  organ  except  as  a  receptacle,  and  that  the 
small  intestine,  with  the  different  juices  which  are  poured  into  it,  is 
abundantly  capable  of  doing  alone  the  entire  digestive  work.  The 
stomach  has  been  excised  from  man  and  in  several  cases  a  fair  measure 
of  digestion  has  been  retained. 

The  really  important  action  of  the  stomach  consists  in  digesting  a 
single  class  of  foods  —  namely,  proteids  —  and  this  process  is  not 
always  finished,  whereas  the  intestine  digests  not  only  proteids,  but 
fats,  starches,  and  sugars.  The  digestion  of  starch,  inaugurated  by 
ptyalin  in  the  mouth,  is  continued  for  a  varying  length  of  time  in  the 
stomach,  until  the  hydrochloric  acid  reaction  of  the  gastric  juice  be- 
comes sufficiently  strong  to  inhibit  it.  The  stomach  warms  and 
macerates  all  classes  of  food,  so  that  it  relieves  the  small  intestine  of 
much  preliminary  work. 

Quantity  of  Gastric  Juice  and  Other  Digestive  Fluids. —  No  exact 
estimates  of  the  quantity  of  gastric  juice,  or,  in  fact,  of  any  of  the 
several  digestive  fluids,  are  obtainable,  for  such  estimates  vary  greatly 
according  to  different  authorities.  An  abundant  secretion  is  not  nec- 
essarily an  active  one  in  ferment  or  acid,  and  the  constant  reabsorp- 
tion  of  the  water  makes  it  quite  impossible  to  say  how  much  fluid  has 


FOOD  IX   THE  STOMACH  387 

been  secreted,  for  if  the  digestive  juices  be  drained  off  and  measured, 
the  natural  conditions  are  disturbed.  Bile  or  pancreatic  fluid  allowed 
to  drain  off  constantly  through  a  fistula  soon  becomes  altered  in  qual- 
ity and  weakened  in  digestive  power. 

Secretion  of  the  Gastric  Juice. —  When  food  enters  the  stomach  it 
immediately  incites  the  secretion  of  the  gastric  juice.  This  it  does 
at  first  through  mechanical  action,  either  upon  the  nerves  or  the  cells 
of  the  gastric  tubules  themselves.  The  purely  physical  character  of 
the  food  which  is  taken  into  the  stomach  will  therefore,  to  some  ex- 
tent, affect  the  rate  of  secretion  as  well  as  the  composition  of  the 
gastric  juice,  and  foods  are  often  spoken  of  as  being  either  bland  or 
irritating.  The  former  are  those  which  are  soft  or  in  a  fine  state  of 
subdivision,  such  as  well-cooked  farinaceous  articles.  The  latter  are 
the  coarser  forms  of  food  and  condiments,  especially  pepper,  mustard, 
curry,  pickles,  etc.,  which  have  a  more  specific  influence  in  increasing 
the  flow  of  juice.  This  is  probably  due  to  reflex  action  through  the 
nerves  of  the  gastric  mucous  membrane.  The  secretion  is  also  in- 
fluenced by  psychic  processes,  connected  with  the  appetite.  (See 
Appetite,  p.  368.) 

The  gastric  juice  is  secreted  more  abundantly  in  response  to  the 
chemical  stimulus  of  some  substances  than  others,  as,  for  example, 
sodium  chloride  and  carbonate  and  alcohol  when  taken  in  moderate 
dilution.  If,  however,  they  are  taken  to  excess  they  cause  derange- 
ment of  the  gastric  function,  and  congestion  ensues  with  secretion  of 
a  neutral  or  alkaline  mucoid  juice  instead  of  the  true  acid  secretion. 

Haidenhain  has  observed  that  the  mechanical  pressure  of  food 
against  the  stomach  wall  may  be  comparatively  local  and  circum- 
scribed, whereas  the  chemical  stimulation  of  the  food  as  soon  as  it 
begins  to  be  felt,  causes  abundant  secretion  from  the  whole  surface 
of  the  stomach,  which  becomes  red  and  turgescent  from  increased 
vascularity. 

The  flow  of  juice  commences  almost  immediately  after  the  food 
has  entered  the  stomach,  and  it  continues  to  be  secreted  in  varying 
quantity  for  two  or  three  hours.  After  this  period  the  secretion 
gradually  diminishes.  If  the  food  has  not  been  digested  properly 
within  a  limit  of  three  and  a  half  hours,  it  may  fail  to  pass  on  into 
the  intestine,  and  while  remaining  in  the  stomach  it  undergoes  vari- 
ous processes  of  malfermentation  which  are  entirely  different  from  the 
normal.  These  processes  will  be  more  fully  discussed  under  the 
headings  of  the  several  forms  of  dyspepsia. 

Hydrochloric  Acid. —  Hydrochloric  acid  exists  in  the  human  gastric 
juice  in  the  average  proportion  of  0.2  per  cent.  Experimentally  it 


FOOD  DIGESTION 

is  found  that  the  best  proteolytic  digestion  results  with  0.1  to  0.2  per 
cent  of  hydrochloric  acid.  The  acidity  is  slightly  reduced  upon  a 
vegetable  diet. 

The  acid  is  secreted  during  active  digestion  but  not  normally  at 
other  times.  It  is  often  diminished  in  quantity,  and  less  often  it  may 
be  abnormally  increased.  Its  action  upon  proteids  is  to  cause  them  to 
swell,  become  somewhat  translucent,  and  it  converts  a  portion  of  them 
into  acid  albumin.  It  contributes  the  necessary  acid  reaction  in 
which  the  ferment  pepsin  causes  solution  of  these  and  other  proteids 
and  converts  them  into  albumoses  or  proteoses,  and  lastly  peptones. 

The  quantity  of  free  acid  obtainable  from  the  stomach  is  not  great 
when  much  proteid  food  has  been  eaten,  although  its  secretion  may 
have  been  considerable.  The  secretion  of  the  acid  begins  shortly  after 
the  ingestion  of  food,  and  reaches  a  maximum  within  about  an  hour. 
After  an  hour  or  two  longer,  according  to  the  nature  and  quantity  of 
the  food  present,  it  lessens  and  finally  ceases. 

Roberts  furnished  the  following  table  illustrating  the  effect  of 
varying  quantities  of  hydrochloric  acid  on  the  speed  of  peptic  di- 
gestion : 

Proportion  of  dry  HCl  in  Time  in  which  digestion 

the  digesting  mixture.  u~as  completed. 

0.05  per  cent 500  minutes,   almost  no   digestion. 


0.08 

0.1 

0.15 

0.2 

0.3 

0.4 

0.6 


200 
130 
115 
100 
115 
160 
350  minutes,  embarrassed. 


The  acid  has  an  antiseptic  influence,  preventing  the  decomposition 
of  food  and  checking  it  if  already  begun. 

Pepsin. —  Pepsin  is  a  hydrolytic  ferment  which  is  found  in  the 
cells  of  the  tubules  of  the  gastric  mucous  membrane,  chiefly  near  the 
cardiac  portion.  According  to  Chittenden  it  exists  in  these  cells  in 
an  antecedent  form,  or  as  a  granular  "  proenzyme,"  which  is  called 
"  pepsinogen  "  or  "  propepsin,"  and  the  agent  which  is  believed  to  con- 
vert the  propepsin  into  true  pepsin,  the  active  ferment,  is  hydro- 
chloric acid.  This  theory  assigns  a  new  function  to  this  acid.  Lactic 
and  acetic  acids  derived  from  food  possess  the  same  power  in  lesser 
degree.  Like  the  other  digestive  ferments,  pepsin  belongs  to  the 
class  of  colloid  or  non-crystallizable,  indiffusible  substances. 

The  rapidity  of  digestion  is  augmented  only  up  to  a  certain  point 
by  increase  in  the  quantity  of  pepsin,  but  beyond  this  limit  it  has  no 
accelerating1  influence  —  no  influence  at  all,  in  fact. 


FOOD   IN   THE  STOMACH  389 

Eecently  Pawlow  has  demonstrated  that  the  same  gastric  ferments 
have  more  than  one  activity,  possess  both  peptic  and  milk-curdling 
function,  and  are  activated  by  a  new  series  of  ferments  known  as 
"  kinates,"  or  "  activators." 

Rennin  has  been  described  on  p.  83. 

Albumoses,  Peptones. —  The  final  product  of  food  digestion  as  ac- 
complished by  pepsin  with  the  hydrochloric  acid  of  the  gastric  juice 
is  peptone.  Kuhne  showed  that  peptone  is  seldom,  if  ever,  formed 
pure  in  the  stomach,  but  the  substance  there  produced  is  a  mixture 
of  true  peptone  with  proteoses  or  albumoses,  which  have  reactions  that 
in  many  respects  are  similar.  The  albumoses  are  more  highly  diffu- 
sible than  peptones.  Undoubtedly  both  peptones  and  albumoses  are 
formed  during  digestion,  and  both  may  be  absorbed  from  the  stomach 
in  small  quantity. 

The  albumoses  may  be  separated  from  peptones  by  complete  pre- 
cipitation by  saturation  in  aqueous  solution  with  sulphate  of  ammo- 
nium. 

Politzer,  Gerlach,  and  others  have  demonstrated  experimentally 
that  albumoses  can  support  nutrition  and  even  cause  gain  in  weight 
when  given  alone  and  free  from  peptones,  and  Hildebrandt  found 
that  the  nitrogen  of  albumoses  artificially  fed  to  animals  was  utilized 
in  the  nutrition  of  the  body  to  an  even  greater  degree  than  the  pep- 
tones of  meat. 

Digestion  of  Proteids  in  the  Stomach. —  The  various  albuminoids 
are  digested  best,  each  with  a  different  degree  of  acidity,  and  it  is 
probable  that  throughout  a  meal  the  intensity  of  reaction  of  the  gas- 
tric juice  varies  considerably,  becoming  stronger  as  more  food  is  ab- 
sorbed or  more  juice  is  formed,  or  weaker  as  more  of  it  passes  with 
the  chyme  into  the  pylorus  or  as  it  is  more  diluted  with  additional 
food  or  drink.  In  this  manner  the  different  proteids  are  all  certain 
of  a  fair  opportunity  for  timely  digestion. 

The  products  of  proteid  digestion  in  the  stomach  have  been  care- 
fully anaylzed  by  Kuhne  and  Chittenden,  and  are  found  to  succeed 
each  other  in  the  following  order : 

1.  Albuminoids  or  proteids. 

2.  Syntonin  or  acid  albumin. 

3.  Albumoses  or  proteoses  —  proto-albumose  (protoproteose),  hetero- 
albumose  (heteroproteose),  deutero-albumose  (deuteroproteose).     The 
latter  form  — 

4.  Peptones. 

Peptones  in  the  intestine  undergo  katabolism  through  action  of 
erepsin,  the  cleavage  taking  place  in  the  intestinal  mucosa. 


390  FOOD  DIGESTION 

Baw  meat  in  the  stomach  turns  gray-brown  and  swells,  the  connec- 
tive tissue  is  first  broken  down  by  gastric  juice,  then  the  sarcolemma, 
and  finally  the  substance  between  the  striae  of  the  muscle  fibers. 
(Compare  Eaw  Meat,  p.  127,  and  Digestibility  of  Meats,  p.  128.) 

Vegetable  albumin  is  digested  in  the  stomach  in  a  manner  quite 
similar  to  the  digestion  of  animal  proteid. 

Gluten  and  vegetable  casein  are  also  dissolved  by  the  gastric  juice 
when  strongly  acid. 

Gelatin  is  one  of  the  substances  most  easily  dissolved  in  the  stom- 
ach. It  is  altered  by  the  hydrochloric  acid  of  the  gastric  juice,  so 
that  it  no  longer  can  be  solidified  by  cold.  It  is  finally  converted  into 
a  diffusible  substance  somewhat  resembling  peptones,  but  not  identical 
with  them. 

Peristalsis. —  In  addition  to  exciting  secretion  upon  entering  the 
stomach,  the  food,  at  first  by  mechanical  action  and  subsequently 
possibly  through  chemical  stimulation,  excites  more  or  less  rhythmical 
peristaltic  movement  in  the  muscular  coat  of  the  stomach.  The  ob- 
ject of  this  movement  is  fourfold:  1.  To  mingle  the  contents  of 
the  food  thoroughly  with  the  gastric  juice.  2.  To  cause  moderate 
trituration  of  the  particles  of  food  which  are  made  to  move  in  cur- 
rents. 3.  To  bring  the  food  in  contact  successively  with  different 
portions  of  the  mucous  membrane,  and  thus  to  stimulate  it  and 
favor  absorption.  4.  To  favor  the  occasional  emptying  of  a  portion 
of  the  contents  of  the  stomach  into  the  duodenum,  the  move- 
ment at  this  time  being  accompanied  by  a  relaxation  of  the  pyloric 
orifice. 

Peristaltic  action  is  influenced  by  the  nature  and  composition  of 
the  food  ingested,  and  it  also  may  be  stimulated  in  other  ways,  which 
will  be  described  more  fully  in  connection  with  intestinal  peristalsis 
(see  Diarrhoea  and  Constipation),  for  it  may  be  said  in  general  that 
those  stimuli  which  affect  intestinal  peristalsis  also  influence  this 
peculiar  movement  in  the  stomach. 

Duration  of  Gastric  Digestion  of  Different  Foods. —  Bauer  says: 
"  By  the  digestibility  of  a  food  one  can  obviously  understand  nothing 
more  or  less  than  the  sum  of  the  resistances  that  it  offers  to  the  action 
of  the  gastric  juice." 

The  time  required  for  gastric  digestion  cannot  be  stated  with  abso- 
lute accuracy.  In  general,  the  period  for  the  full  digestion  of  a 
mixed  meal  consisting  of  bread,  meat,  and  vegetables  is  three  and  a 
half  hours,  but  because  some  kinds  of  food  are  thoroughly  digested  in 
the  stomach,  while  others  are  acted  upon  but  little  if  at  all,  the  pre- 
ponderance of  one  or  other  article  of  food  in  a  mixed  diet  may  affect 


FOOD   IX   THE   STOMACH  391 

somewhat  the  whole  period  of  digestion.  (See  Digestibility  of  Meats, 
p.  128.) 

The  duration  of  gastric  digestion  depends  upon:  1.  The  variety 
and  quantity  of  food  eaten.  2.  Its  state  of  subdivision,  solubility, 
complexity,  and  the  process  of  its  cooking.  3.  The  thoroughness  of 
mastication  and  rate  of  deglutition.  4.  The  activity  of  the  stomach. 
5.  The  interval  which  has  elapsed  since  the  previous  meal.  6.  The 
condition  of  the  blood  and  nerve  supply  of  the  gastric  glands.  7.  The 
activity  of  peristaltic  movement,  which  may  either  retard  or  hurry 
the  rate  of  emptying  the  stomach.  8.  The  amount  of  fluid  drunk 
with  which  the  gastric  juice  is  diluted.  9.  The  strength  of  the  im- 
portant ingredients  of  this  juice,  its  volume,  and  the  effect  upon  it 
of  food  itself,  neutralizing  it  or  not.  10.  The  rate  of  gastric  absorp- 
tion. 11.  Habit.  12.  Idiosyncrasy.  13.  The  presence  of  excess  of 
fat  or  other  materials  incapable  of  digestion  in  the  stomach.  14.  The 
diversion  of  the  nervous  energy  required  for  digestion  to  other  func- 
tions, such  as  mental  or  muscular  work. 

Such  statements  are  often  definitely  made  in  articles  upon  die- 
tetics as  that  boiled  mutton  requires  three  hours  for  stomach  diges- 
tion, while  roasted  mutton  requires  three  hours  and  eighteen  min- 
utes; that  raw  oysters  require  one  hour  and  fifty-five  minutes  and 
roasted  oysters  two  hours  and  eleven  minutes;  that  boiled  carrots 
require  three  hours  and  sixteen  minutes,  and  the  like.  These  figures 
may  impress  the  lay  mind  as  being  of  interest  and  accuracy,  but  when 
the  above  considerations  have  been  taken  into  account,  it  must  be 
seen  that  they  are  far  from  reliable.  It  is  important,  however,  to 
ascertain,  if  possible,  the  approximate  time  required  for  gastric  diges- 
tion of  certain  general  classes  of  food,  and  the  following  estimates 
are  as  nearly  correct  as  possible  in  view  of  the  above  statements. 

The  average  time  required  for  meats  cooked  by  broiling,  roasting, 
or  boiling  is  fully  three  or  three  and  a  half  hours  for  their  complete 
gastric  digestion,  but  much  depends  upon  the  ease  with  which  the 
gastric  juice  can  penetrate  their  muscle  fibers.  (The  subject  of  the 
relative  digestibility  of  various  meats  is  discussed  in  connection  with 
their  nutriment  value  on  page  129.) 

Some  of  the  viscera  of  animals  which  are  eaten  as  food,  such  as 
brains,  tripe,  liver,  and  kidneys,  are  digested  in  less  time  —  approxi- 
mately two  hours.  Fish  and  shellfish  require  from  two  and  a  half 
to  three  hours  for  their  digestion.  Eaw  eggs  are  usually  digested  in 
less  time  than  cooked  ones,  and  they  may  be  ready  for  absorption  in 
two  hours,  whereas  hard-boiled  eggs  require  at  least  three  and  a  half 
hours.  Milk  is  usually  digested  somewhat  sooner  when  boiled  than  if 


392  FOOD  DIGESTION 

raw.  Milk  whey  is  absorbed  from  the  stomach,  but  the  curds  often 
pass  on  into  the  duodenum. 

The  majority  of  the  heavier  vegetables,  such  as  peas,  beans,  corn, 
beets,  turnips,  etc.,  remain  in  the  stomach  between  three  and  three 
and  a  half  hours,  but  potatoes,  if  baked  and  mealy,  may  remain  only 
two  and  a  half  hours.  Eaw  vegetables,  such  as  coleslaw  or  raw  cab- 
bage and  lettuce,  etc.,  may  remain  two  and  a  half  hours  or  more  in 
the  stomach,  and  the  same  is  true  of  most  raw  fruits,  such  as  berries, 
apples,  pears,  peaches,  etc.  The  more  digestible  cereals,  such  as  rice, 
hominy,  and  also  sago,  tapioca,  etc. —  should  pass  from  the  stomach 
within  two  hours.  Fats  and  oils  taken  alone  may  remain  in  the 
stomach  only  a  few  moments  before  entering  the  intestine.  Sugars 
may,  to  some  extent  at  least,  be  absorbed  from  the  stomach  wall  in  the 
course  of  the  first  hour  of  digestion. 

Gastric  juice  being  fairly  constant  in  composition,  its  effect  in 
health  upon  the  duration  of  digestion  of  the  same  kind  of  food  may 
not  vary  in  the  same  individual ;  but  persons  differ  from  one  another 
very  much  in  the  rapidity  of  their  digestive  processes.  In  some  per- 
sons, even  in  health,  stomach  digestion  may  be  uniformly  an  hour  or 
more  slower  than  it  is  in  others.  Variations  from  the  usual  period 
of  digestion  are  almost  always  upon  the  side  of  its  retardation. 

Coarse  food,  badly  cooked  starchy  food,  excess  of  fats,  tough-fibered 
meats,  unripe  fruits  or  vegetables,  all  retard  digestion,  and  may  prove 
very  irritant. 

Among  articles  of  diet,  substances  are  sometimes  eaten  which  are 
purely  refuse  material,  such  as  the  skins  of  potatoes  and  of  coarse 
fruits,  grape  seeds,  shells  of  soft-shell  crabs,  etc.  They  may  pass  on 
unaltered  into  the  intestine  and  cause  diarrhoea,  or  may  linger  for 
several  days  and  excite  reflex  irritation. 

(The  temperature  of  food  and  drink  as  affecting  gastric  digestion 
is  discussed  under  the  heading  Temperature  and  Digestion,  p.  374.) 

Abnormalities  of  Gastric  Digestion.1  —  Hypersecretion  or  increase 
in  quantity  of  gastric  juice  gives  rise  to  thirst,  sour  eructations, 
and  more  or  less  epigastric  distress.  The  secretion  may  digest  pro- 
teids  well,  but  carbohydrates  are  ill  borne  in  this  condition, 
which  is  believed  to  be  caused  chiefly  by  some  form  of  neurosis. 
An  excess  of  more  or  less  acid  gastric  juice  passes  on  with  the 
chyme  into  the  small  intestine,  and  causes  an  acid  reaction  therein, 
requiring  more  of  the  intestinal  digestive  fluids  —  bile,  pancreatic 
juice,  etc. —  to  neutralize  it.  The  saliva  is  often  increased  at  the 

i  The  clinical  examination  of  the  stomach  contents  is  described  under  sepa- 
rate heading  on  p.  572. 


FOOD  IN   THE  INTESTINE  393 

same  time,  and  Eoberts  suggests  that  this  may  be  a  provision  of 
Nature  to  neutralize  the  acid  in  the  stomach, 

Hyperacidity  or  increase  in  the  hydrochloric  acid  of  the  gastric 
juice,  does  not  necessarily  imply  hypersecretion  of  juice. 

Hyperacidity  is  common,  and  prone  to  be  present  in  connection 
with  gastric  ulcer  and  certain  forms  of  chronic  dyspepsia. 

Anacidity  or  the  persistent  absence  of  hydrochloric  acid  from  the 
gastric  secretion,  does  not  indicate  the  presence  of  any  one  disease. 
It  may  be  absent  in  nervous  dyspepsia  without  organic  lesion,  or  with 
carcinoma. 

Pyrosis,  or  eructation  of  gas  from  the  stomach,  if  it  occurs  soon 
after  ingestion  of  food,  is  usually  due  to  lactic  or  other  organic  acid 
fermentation.  Occurring  later,  during  active  digestion,  it  may  be  due 
to  the  same  cause  or  to  hyperacidity  from  excess  of  hydrochloric  acid. 
When  due  to  lactic  acid,  the  giving  of  hydrochloric  acid  stops  fur- 
ther fermentation.  Sodium  bicarbonate,  although  it  momentarily 
neutralizes  lactic  acid,  soon  produces  an  alkaline  reaction  in  which  the 
further  development  of  the  acid  rapidly  proceeds.  On  the  other  hand, 
pyrosis  due  to  hydrochloric  acid  may  be  checked  by  alkalies. 


FOOD  IN  THE  INTESTINE 

After  preliminary  maceration  under  conditions  of  the  moisture, 
warmth,  and  motion  in  the  stomach,  and  after  partial  digestion  there, 
the  food,  mixed  with  gastric  juice,  passes  in  a  pultaceous  mass,  known 
as  chyme,  into  the  duodenum.  Here  the  physical  conditions  are  al- 
most identical  with  those  found  in  the  stomach,  but  the  chemical  com- 
position of  the  new  digestive  juices  —  namely,  the  bile  and  pancreatic 
and  intestinal  juices  —  is  alkaline,  and  a  number  of  new  ferments 
complete  the  solution  and  digestion  of  the  food. 

The  starches  which  were  only  partly  digested  by  the  saliva  are 
converted  into  dextrin,  maltose,  and  glucose  by  a  diastatic  ferment  — 
amylopsin  —  contained  in  the  pancreatic  juice.  Cane  sugar  is  con- 
verted by  the  intestinal  juice  into  glucose. 

Proteids  which  have  escaped  complete  gastric  digestion  are  con- 
verted successively  into  (1)  alkali  albumins,  (2)  deutero-proteose,  (3) 
antipeptone  and  amido  acids.  Those  proteids,  on  the  other  hand, 
which  the  gastric  juice  has  altered  into  proteoses,  albumoses  or  pep- 
tones are  further  converted  into  antipeptone  and  amido  acids,  through 
action  of  the  trypsin  ferment  of  the  pancreatic  juice.  In  this  latter 
form  of  antipeptones,  the  proteid  foods  are  chiefly  absorbed  from  the 
28 


394  FOOD   DIGESTION 

small  intestine,  not  more  than  about  14  per  cent  being  absorbed  from 
the  large  intestine. 

Pancreatic  juice  is  the  most  active  and  comprehensive  digestive 
fluid  of  the  body.  It  is  not  only  stronger  than  the  gastric  juice  in 
action  upon  proteids,  being  able  to  form  peptones  with  fewer  inter- 
mediate products,  but  possesses  the  distinct  advantage  that  it  also 
digests  fats  and  carbohydrates  by  a  ferment,  called  steapsin,  which 
acts  in  either  acid  or  alkaline  media. 

Its  amylolytic  power  is  stronger  than  that  of  the  saliva,  for  it  di- 
gests the  raw  starch  and  cellulose  which  is  eaten  in  such  vegetables 
as  celery,  lettuce,  or  radishes,  and  in  fruits  like  the  apple. 

It  is  made  active  through  the  agency  of  entero-kinase,  one  of  the 
newly  discovered  activator  group  of  ferments. 

Trypsin  acts  best  in  a  medium  rendered  alkaline  by  from  0.5  to  1 
per  cent  sodium  bicarbonate.  It  also  digests  proteids  energetically 
in  a  neutral  medium,  but  free  acid  soon  destroys  it.  E.  H.  Chittenden 
has  shown  that  combined  acids  do  not  necessarily  stop  trypsin  pro- 
teolysis. 

The  l>ile  plays  several  roles  in  intestinal  digestion,  but  its  chief  ac- 
tion is  in  aiding  the  emulsion  of  fats,  described  below.  It  can  accom- 
plish the  absorption  of  fats  in  the  absence  of  pancreatic  juice.  When 
bile  is  absent  the  fatty  food  may  decompose  in  the  intestine  and  de- 
velop gases  and  foul  odors. 

Voit  says  that  the  white  color  of  icteroid  stools  is  dependent  rather 
upon  the  presence  of  undigested  fat  than  the  absence  of  bile,  for  with 
a  meat  instead  of  a  milk  diet  they  may  still  be  of  a  dark  color. 
When  a  biliary  fistula  is  made  in  dogs  and  the  bile  is  drained  away, 
they  emaciate  and  have  a  ravenous  appetite  if  fed  upon  meats  and 
fats,  but  not  if  fed  upon  carbohydrates. 

The  quantity  of  bile  secreted  is  increased  by  a  proteid  diet,  and 
diminished  upon  an  exclusive  fat  diet  (Uffelmann).  Vegetable  foods 
color  the  bile  green ;  animal  foods  make  it  yellow  or  orange. 

Bile  is  often  said  to  prevent  putrefactive  changes  in  the  food  in 
the  intestine.  It  is  not,  however,  an  antiseptic  substance,  for,  unlike 
the  gastric  juice,  it  easily  undergoes  decomposition,  and  the  influence 
attributed  to  it  is  due  rather  to  its  promotion  of  peristalsis,  thereby 
keeping  the  intestinal  contents  moving  and  preventing  stagnation  and 
putrefaction. 

Digestion  of  Fats. —  When  fat  is  cooked  in  food,  much  of  it  is 
converted  into  rancid  fat  —  i.  e.,  fat  containing  free  fatty  acids.  In 
the  mouth  the  fatty  food  is  unaltered,  unless  it  be  in  the  form  of 
adipose  tissue,  when  the  process  of  mastication  breaks  it  down  and  lib- 


FOOD  IN   THE  INTESTINE  395 

erates  some  of  the  fat  globules,  which  are  melted  by  the  natural 
warmth.  If  eaten  in  the  form  of  oil  or  butter,  with  starchy  or  veg- 
etable food,  the  fat  coats  the  particles  of  food  in  the  mouth.  Bread 
thus  mingled  with  butter  is  less  likely  to  form  a  large  and  too  tena- 
cious bolus. 

In  the  stomach  fat  remains  unaltered,  and  when  the  semifluid 
chyme  begins  to  flow  into  the  intestine  it  passes  in  with  it.  The  con- 
nective tissue  elements  of  fatty  meats,  etc.,  are  digested  like  other 
proteids. 

In  the  intestine  fat  is  subjected  to  a  double  process  of  emulsifica- 
tion  and  saponification,  which  is  accomplished  by  the  combined  action 
of  the  bile  and  pancreatic  juice.  The  latter  splits  fats  into  glycerin 
and  fatty  acid,  and  this  action  is  favored  by  the  admixture  with  bile, 
which  simultaneously  occurs  in  the  duodenum.  According  to  Rach- 
ford,  the  fat-splitting  power  of  pancreatic  juice  is  more  than  quad- 
rupled by  the  agency  of  bile,  although  the  latter  has  no  fat-splitting 
influence  of  its  own.  He  also  declares  that  the  presence  of  hydro- 
chloric acid  which  has  just  entered  the  upper  duodenum  with  the 
chyle,  like  the  bile,  still  further  aids  the  pancreatic  action  upon  fats, 
as  four  to  one. 

It  is  held  by  the  majority  of  authorities  that  pancreatic  juice  also 
contains  an  emulsifying  ferment,  steapsin,  and  that  the  free  fatty  acid 
above  described  splits  up  the  sodium  bile  salts  and  liberates  their 
sodium,  which  unites  with  a  portion  of  the  free  fatty  acid,  forming  a 
soap.  The  soap  coats  the  droplets  of  emulsified  fat  with  a  thin  film 
(like  a  soap  bubble)  and  prevents  them  from  coalescing  again.  The 
emulsion  is  then  absorbed  by  the  lacteals. 

It  is,  however,  not  a  necessary  part  of  the  theory  of  digestion  of 
fatty  food  that  the  fat  must  all  be  emulsified.  No  doubt  a  large  part 
of  it  is  absorbed  more  directly  or  as  a  soap  without  emulsification. 

Extracts  of  both  the  liver  and  spleen  have  been  said  to  favor  the 
absorption  of  fats  by  emulsification. 

Undigested  food  reaches  the  intestines  under  the  following  con- 
ditions :  (a)  When  the  food  is  improper  in  kind,  (&)  when  too  much 
food  is  eaten,  (c)  when  gastric  digestion  is  imperfect,  (d)  when  the 
motility  of  the  stomach  is  abnormally  increased. 

Intestinal  Gases. —  During  the  digestion  of  certain  foods  in  the 
intestine  more  or  less  gas  is  evolved.  The  gas,  by  distending  the 
walls  of  the  gut,  serves  the  purpose  of  keeping  them  from  agglu- 
tinating, and  thereby  facilitates  the  free  movement  and  intermingling 
of  the  digestive  fluids  and  food,  and  the  absorption  of  the  latter. 

"Ruge  has  published  the  following  table  of  the  percentage  of  gases 


396 


FOOD   DIGESTION 


evolved  by  several  different  kinds  of  foods  (in  which  the  numbered 
columns  represent  separate  samples)  : 


GAS. 

MILK. 

MEAT. 

PEAS  OR  BEANS. 

1. 

2. 

1. 

2. 

3. 

1. 

2. 

3. 

CO2     

16.8 
43.3 
0.9 
38.3 

9.9 
54.2 

SG'.I 

13.6 
3.0 
37.4 
45.9 

12.4 
2.1 
27.5 

57.8 

8.4 
0.7 
26.4 
64.4 

34.0 

2.3 
44.5 
19.1 

38.4 
1.5 
49.3 
10.6 

21.0 
4.0 
55.9 
18.9 

H    

CH4    

N, 

Test  for  Intestinal  Digestion 

Max  Einhorn  has  devised  a  test  for  intestinal  digestion.  Small 
beads  are  filled  with  fragments  of  meat,  hot  fat  which  congeals,  etc. 
They  are  strung  together  with  catgut,  placed  within  a  gelatin  capsule 
and  swallowed.  In  from  one  to  two  days  they  appear  in  the  stools 
and  examination  of  their  contents  shows  whether  digestion  of  the  in- 
gredients has  been  imperfect. 


ARTIFICIAL  DIGESTION 

The  different  ferments  which  may  be  used  for  increasing  the  ac- 
tivity of  digestion  within  the  body  or  for  partially  digesting  foods 
outside  of  the  body  are  principally  diastase,  pepsin,  and  extracts  of 
pancreatic  juice,  usually  called  "  pancreatin "  and  which  are  com- 
pounds of  several  substances.  Besides  these  there  are  several  vegeta- 
ble ferments,  such  as  papain  from  the  American  papaw,  and  ferments 
present  in  the  juice  of  the  pineapple,  the  century  plant  or  agave,  vari- 
ous lichens  and  gums. 

Predigestion  of  Starches. —  There  are  a  variety  of  ferments  and 
other  materials  which  have  the  power  of  converting  starch  into  dex- 
trin and  sugar.  They  are  ptyalin  in  the  saliva,  amylopsin  in  the 
pancreatic  juice,  diastase,  a  ferment  in  the  intestinal  juice,  and  the 
substances  inulin  and  lichenin.  The  latter  is  obtainable  from  lichens, 
such  as  Iceland  moss.  Mucin  and  certain  gums  are  also  amylolytic. 
Of  these  the  one  which  is  of  the  most  practical  service  is  diastase. 

Diastase. —  The  action  of  the  diastase  of  malt  resembles  that  of  the 
ptyalin  of  the  saliva  and  the  amylopsin  of  the  pancreatic  juice,  which 
alter  starches  into  dextrin  and  maltose.  It  is  prepared  in  several 
ways,  for  example,  as  a  meal  made  of  malt,  which  may  be  added  to 
farinaceous  food*,  and  in  the  form  of  malt  extracts,  and  various 
malted  foods  (malted  milk,  etc.)  are  sold  for  invalid  use  or  for  infant 
feeding.  (See  Malt  Extracts,  p.  189.) 


ARTIFICIAL  DIGESTION  397 

Takadidstase  is  a  stable  concentrated  form  of  diastase,  devised  by 
Dr.  Takamene,  and  said  to  possess  the  power  of  converting  100  times 
its  weight  of  starch  into  sugar  in  ten  minutes.  The  dose  is  2l/2 
grains  after  eating. 

In  such  preparations  the  predigestion  of  amylaceous  foods  is  car- 
ried to  the  extent  of  more  or  less  complete  conversion  of  tne  starch 
into  dextrin  and  maltose.  The  diastase  has  no  action  in  the  stomach 
provided  the  acid  gastric  juice  is  being  secreted,  for  it  only  causes 
fermentation  in  a  neutral  or  alkaline  medium;  in  fact,  the  ferment 
is  probably  destroyed  before  reaching  the  intestine,  but  it  may  act  in 
the  stomach  for  half  an  hour  or  more  before  the  reaction  of  the  gastric 
juice  becomes  too  strongly  acid.  The  presence  of  alkaline  carbonates 
also  retards  the  action  of  diastase.  In  early  infancy  the  amylolytic 
ferments  of  the  salivary  and  pancreatic  fluids  are  not  well  developed 
and  are  meager  in  quantity.  If  a  young  child  be  unable  to  digest 
milk  for  any  reason,  malted  food  may  temporarily  be  supplied.  In 
general,  the  value  of  malted  foods  and  malt  extracts  depends  upon 
the  predigested  starch  which  they  contain,  which  furnishes  nutriment, 
rather  than  upon  the  action  of  the  diastatic  ferment  within  the  ali- 
mentary canal. 

Ground  malt  possesses  stronger  digestive  action  upon  starches  than 
malt  extracts.  The  latter  contain  the  ferment  diastase,  dextrin,  mal- 
tose, and  a  portion  of  the  salt  and  some  nitrogenous  ingredients  of 
barley.  Both  ground  malt  and  malt  extracts  digest  starches  at  a 
moderate  heat,  not  exceeding  150°  F.  There  are  many  varieties  of 
malted  food,  types  of  which  are  described  upon  page  189. 

Predigestion  of  Proteids. —  The  digestion  of  proteids  may  be  ac- 
complished either  within  the  body  by  prescribing  pepsin  and  hydro- 
chloric acid,  or  without  the  body  by  use  of  the  same  agents,  or,  as  it  is 
more  often  done  at  present,  by  pancreatinization. 

Pepsin  was  the  first  among  the  digestive  ferments  to  be  isolated  and 
employed  for  artificial  fermentation. 

This  ferment  may  be  prescribed  in  cases  of  deficient  gastric  secre- 
tion, to  be  taken  with  meals,  or  immediately  after,  as  a  powder  or  in 
solution.  The  action  of  pepsin  is  confined  to  the  digestion  of  proteid 
food,  and  it  requires  an  acid  reaction. 

It  is  prepared  in  a  number  of  forms,  such  as  scales,  dry  powder, 
pills,  and  solution.  There  is  considerable  variation  in  the  strength 
of  the  preparations,  depending  upon  the  care  taken  in  their  manufac- 
ture and  differences  in  the  processes  of  extracting  the  ferment ;  but  all 
of  them  have  some  digestive  action,  although  they  are  less  serviceable 
than  pancreatine. 


398  FOOD  DIGESTION 

In  regard  to  the  artificial  digestion  of  proteids  by  pepsin,  Chitten- 
den  says :  "  Peptones  are  truly  formed,  and  many  times  in  large 
amount,  but  never  under  any  circumstances  have  I  been  able  to 
effect  a  complete  transformation  of  any  proteid  into  true  peptone  by 
pepsin-proteolysis ;  there  is  always  found  a  certain  amount  of  pro- 
teoses  more  or  less  resistant  to  the  further  action  of  the  ferment. 
Even  with  a  large  amount  of  active  ferment,  an  abundance  of  free 
hydrochloric  acid,  a  proper  temperature,  and  a  long-continued  period 
of  digestion,  even  five  and  six  days,  there  is  never  found  a  complete 
conversion  into  peptone.  Indeed,  the  largest  yield  of  peptone  I  ever 
obtained  in  an  artificial  digestion  is  60  per  cent,  while  the  average 
of  a  large  number  of  results  under  most  favorable  circumstances  is 
somewhat  less  than  50  per  cent/'  Hence,  artificial  pepsin  is  not  a 
complete  digester,  as  often  supposed,  and  too  great  reliance  should 
not  be  placed  upon  it. 

Pepsin  should  never  be  given  in  combination  with  an  alkali,  such 
as  sodium  bicarbonate. 

The  pepsin-secreting  cells  predominate  over  the  acid-forming  cells 
in  the  stomach  so  largely  that  they  are  seldom  destroyed  to  the  same 
degree  as  the  latter,  and  hence  pepsin  is  of  much  less  importance  than 
hydrochloric  acid  in  the  treatment  of  both  functional  and  organic 
disease  of  the  stomach.  It  is  a  very  common  practice  to  prescribe  it 
in  tablet  form  without  acid,  but  as  a  rule,  to  which  there  are  almost 
no  exceptions  other  than  that  of  hyperacidity,  in  those  cases  in  which 
the  exhibition  of  pepsin  is  indicated  hydrochloric  acid  is  equally  if  not 
more  important. 

The  pepsin  is  given  in  doses  of  three  to  five  or  ten  grains  imme- 
diately after  meals  when  proteid  food  of  any  kind  has  been  eaten. 
Ten  grains  may  be  added  to  a  pint  of  milk,  but  if  long  continued  in 
excess  of  twenty  grains  per  diem,  it  may  excite  purgation. 

Pancreatin  is  the  name  given  to  a  complex  fermentative  body  de- 
rived from  extracting  the  pancreatic  gland.  It  is  prepared  in  the 
form  of  a  dry  powder,  and  also  as  a  solution  or  liquor.  Its  introduc- 
tion is  mainly  due  to  the  researches  of  Dr.  William  Eoberts,  of  Lon- 
don. It  is  a  powerful  digestant,  more  serviceable  for  the  prediges- 
tion  of  food  than  any  of  the  other  ferments.  It  contains  both  trypsin 
and  amylopsin.  It  also  emulsifies  fats.  Its  action  is  so  powerful  and 
varied,  that  the  majority  of  the  predigested  food  preparations  —  the  so- 
called  "  peptonized  foods  "-  —  are  made  with  pancreatin  instead  of  pep- 
sin. Pancreatin  is  sometimes  prescribed  by  physicians  for  internal 
use,  but  unless  protected  in  a  keratin  or  similarly  coated  capsule  the 
ferments  are  destroyed  by  the  action  of  the  gastric  juice.  It  is  cus- 


FOOD   ABSORPTION  399 

ternary  to  add  some  alkali,  such  as  sodium  bicarbonate,  to  pancreatin 
in  the  process  of  artificial  digestion,  although  it  will  also  operate  on 
protein  in  the  presence  of  a  neutral  reaction.  (Typical  varieties  of 
pancreatinized  proteids  are  described  under  Fluid  Meat  Preparations, 
p.  135,  and  Pancreatinized  Milk  is  described  on  p.  90.)  A  typical 
pancreatinized  carbohydrate  is  Benger's  Food,  which  is  made  with 
cooked  wheat  meal  and  pancreatic  extract.  The  latter  partially  con- 
verts the  starches  into  malt  and  diastase,  and  when  added  to  milk  at 
the  proper  temperature  for  fermentation,  it  acts  upon  the  casein  and 
converts  it  into  a  soluble  peptone.  Oat  flour  and  lentil  flour  are 
similarly  prepared.  Carnrick's  Infant  Food  is  made  on  the  same 
principle  with  Benger's  Food,  with  wheat  flour,  pancreatin,  and  milk, 
to  which  is  added  a  certain  percentage  of  lactose. 

Papoid  is  a  vegetable  ferment  derived  from  the  papaw  tree  (Carica 
Papaya)  which  is  thus  described  by  E.  H.  Chittenden: 

"  Extended  study  of  the  reactions  of  the  vegetable  ferment  papoid 
shows  that  it  is  composed  essentially  of  a  mixture  of  vegetable  globu- 
lin, albumoses  and  peptone,  with  which  is  associated  the  ferments 
characteristic  of  the  preparation. 

"  Papoid,  so  far  as  my  observations  extend,  has  the  power  of  digest- 
ing to  a  greater  or  less  extent  all  forms  of  proteid  or  albuminous  mat- 
ter, both  coagulated  and  uncoagulated.  Furthermore,  papoid  is 
peculiar  in  that  its  digestive  power  is  exercised  in  a  neutral,  acid,  or 
alkaline  medium. 

"  Papoid  will  act  in  dilute  solutions,  but  the  best  and  characteristic 
action  is  seen  only  when  a  small  volume  of  fluid  is  present.  In  this 
respect  it  differs  very  markedly  from  the  animal  ferment  pepsin." 
After  ingesting  the  ferment  it  is  found  in  the  stools,  showing  that  it 
is  not  wholly  destroyed  in  the  alimentary  canal.  The  dose  is  from 
one  to  three  grains  after  each  meal. 

Caroid  is  a  vegetable  digestive  ferment  made,  like  papoid,  from 
the  papaw  (Carica  Papaya)  in  the  form  of  a  dry  yellowish  powder. 
According  to  Chittenden's  analysis,  it  retains  a  strong  proteolytic 
action  in  either  acid,  neutral,  or  alkaline  media.  It  softens  and  dis- 
integrates proteids,  coagulates  milk  like  rennet,  and  is  also  amylolytic. 
It  is  a  solvent  of  gastric  mucus. 

FOOD  ABSORPTION 

The  absorption  of  food  takes  place  from  the  stomach  to  a  limited 
extent,  to  a  great  degree  from  the  small  intestine,  and  to  a  lesser 
degree  from  the  large  intestine.  The  rectum  is  capable  of  absorb- 


400 


FOOD   DIGESTION 


ing  enough  predigested  food  to  sustain  life  for  several  weeks.  (See 
Food  Enemata.)  The  entire  digestive  process  does  not  have  to  be 
completed  before  absorption  begins.  Usually  those  foods  which  are 
first  digested,  or  which  are  administered  in  predigested  form,  are  first 
absorbed. 

The  rate  of  absorption  depends  upon  the  degree  of  digestibility 
of  the  food,  the  extent  of  absorbing  surface  with  which  it  is  brought 
into  contact  by  the  peristaltic  movement,  the  composition  of  the 
blood,  the  relative  pressure  in  the  intestine,  blood  vessels,  and  lym- 
phatics, and,  probably  more  than  anything  else,  upon  the  functional 
activity  of  the  cells  covering  the  intestinal  villi.  The  accompanying 
table  shows  the  percentage  of  food  swallowed  which  is  actually  ab- 
sorbed : 


WEIGHT  OF  FOOD. 

Absorbed. 

Residue. 

Of  100 

parts  of  solids  of  mixed  diet   

89.9 

11  1 

"             albumin                  

81  2 

18  8 

« 

fats  or  carbohydrates          

96  9 

3  1 

ELIMINATION  OF  FOOD  WASTE 

The  data  given  below,  derived  from  Bauer,  exhibit  the  balance  of 
income  of  food  and  output  of  waste  of  the  body  under  different  con- 
ditions of  rest  and  activity. 

Income  of  Food  and  Output  of  Waste  (Bauer). 


Rest  and 
abundant  diet. 

Work  and 
abundant  diet. 

Small,  ill-nour- 
ished man; 
rest  and 
abundant  diet. 

Income. 
Meat                          

Grams. 

139.7 

Grams. 

151.3 

Grams. 

151.1 

\Yhite  of  efror                          

41.5 

48.1 

61  8 

Bread    .  .            

450.0 

450.0 

450.0 

Milk                                 

500.0 

500.0 

509.6 

Beer    

1,025.0 

1,065.9 

1,012.7 

Suet          

70.0 

60.2 

58.8 

Butter     

30.0 

30.0 

30.0 

Starch     

70.0 

70.0 

70.0 

Sujjar      .      .             .               

17.0 

17.0 

17.0 

Salt   

4.2 

4.9 

4.3 

Water        

286.3 

489.1 

41.4 

Oxygen   from  air                                  .    ... 

709  9 

1,006  1 

600  7 

Total     

3,342.7 

3,892.6 

3,007.4 

ELIMINATION    OF   FOOD    WASTE 

Income  of  Food  and  Output  of  Waste   (Bauer),  Continued. 


401 


Rest  and 
abundant  diet. 

Work  and 
abundant  diet. 

Small,'ill-nour- 
ished  man; 
rest  and 
abundant  diet. 

Output. 
Urine    

Grams. 

1,343  1 

Grains. 

1  261  1 

Grams. 
1  069  6 

Feces  

114  5 

129  0 

137   1 

Breath    

1  739  7 

2  545  5 

1  597  8 

Total  

3  197  3 

Q  QQB;  « 

9  804.  ^ 

Balance     

-i-l  45  4 

^Q    A 

J-909  Q 

The  following  data  are  quoted  by  Yeo : 

"  According  to  Dujardin-Beaumetz,  a  man  loses,  in  connection  with, 
the  processes  of  nutrition,  nitrogen,  carbon,  water,  and  salts.  In 
twenty-four  hours  these  losses  [for  an  adult  man  at  moderate  labor J, 
on  an  average,  amount  to  20  grams  (300  grains)  of  nitrogen,  310 
grams  (4,650  grains)  of  carbon,  30  grams  (450  grains)  of  salts,  and 
3  litres  (about  6  pints)  of  water.  The  chief  part  of  the  nitrogen 
(14.5  grams)  passes  away  in  the  urine  in  the  form  of  urea  and  uric 
acid,  and  the  remainder  (5.5  grams)  in  the  feces,  perspiration  and 
mucous  discharges.  Of  the  carbon,  350  grams  are  eliminated  from 
the  lungs,  45  grams  are  eliminated  by  the  kidneys,  and  15  grams  in 
the  other  secretions.  The  water  passes  off  by  the  skin,  lungs,  kidneys, 
and  bowels.  A  man's  food  must  contain  the  elements  necessary  to 
repair  these  incessant  losses. 

"  The  20  grams  of  nitrogen  represent  124  grams  of  dry  proteid  mat- 
terials,  and  as  these  contain  64  grams  of  carbon,  on  subtracting  the 
64  grams  from  the  300  grams  necessary  for  nutrition  there  remain  236 
of  carbon  to  be  derived  from  starch  substances  or  from  fats." 

As  much  as  0.64  gram  (8  grains)  of  nitrogen  may  be  eliminated 
per  diem  through  the  skin  and  over  0.5  (7~y2  grains)  is  common. 
(Benedict  and  Milner.) 


The  Feces  and  Food 

Until  recently  it  has  been  customary  to  regard  the  feces  as  com- 
posed almost  exclusively  of  the  residue  of  indigestible  food,  i.  e., 
material  which  has  never  been  acted  upon  by  digestive  fluids  or  ab- 
sorbed. Prausnitz,  however,  has  demonstrated  that  this  is  inac- 
curate and  that  a  large  proportion  of  the  feces  consists  of  true 
metabolic  products.  This  fact  has  been  confirmed  at  the  Maine 


402 


FOOD  DIGESTION 


Agricultural  Experiment  Station,  by  Woods  and  Merrill,  and  by 
others.  It  is  thus  important  to  supplement  microscopic  examination 
of  the  feces,  with  chemical  analyses,  especially  as  to  the  nitrogen  out- 
put. Caspari  examined  the  feces  of  a  vegetarian  who  partially  fasted 
for  41  days,  and  found  that  whereas  only  0.86  gram  (13  grains)  of 
nitrogen  was  taken  in  the  food,  1.18  (16  grains)  grams  was  excreted 
per  diem. 

Among  the  food  substances  often  found  in  the  stools  of  healthy 


FIG.  44. —  APPARATUS  FOB  DRYING  FECES  OVER  WATER  BATH. 
a,  Section  of  can;  6,  water  reservoir;  c  and  d,  tubes  for  preserving  constant 
level  of  water  in  bath ;  e,  e,  valves  regulating  water  supply  for  reservoir ; 
/,  overflow  pipe  for  water  bath.      (H.  W.  Wiley,  Bull.  84,  Part  I,  Health 
Bur.  of  Chem..  U.  S.  Dept.  Agri.) 

persons  who  have  eaten  with  imperfect  mastication,  or  have  eaten 
coarse  food  imperfectly  cooked,  are:  Meat  fibers,  fragments  of  con- 
nective tissue,  tendons  and  cartilage,  seeds  of  many  kinds,  husks  of 
grain,  the  rough  outer  envelope  of  peas,  beans,  corn,  etc.,  vegetable 
fibers  (celery,  rhubarb,  etc.), 


THE  URINE  AND  FOOD 

The  relation  of  the  composition  of  the  urine  to  the  quality  and 

quantity  of  the  food  is  highly  important. 


THE  URINE  AND  FOOD  403 

Independently  of  renal  disease  and  of  excessive  perspiration,  the 
occurrence  of  a  scanty  urine  means  that  too  little  fluid  is  being  in- 
gested, and  that  proteid  waste  is  accumulating  faster  than  it  is  being 
removed. 

The  urine  excretion  is  normally  increased  in  quantity  after  meals, 
and  is  diminished  during  fasting  and  in  sleep.  The  increased  rate 
of  excretion  lasts  two  or  three  hours,  and  then  lessens.  The  in- 
crease usually  begins  within  an  hour  after  breakfast,  but  not  for  two 
or  three  hours  after  dinner.  This  may  be  owing  to  the  slower  absorp- 
tion of  fluid  which  occurs  with  the  heavier  meal  —  i.  e.,  while  solid 
food  is  retained  in  the  alimentary  canal,  it  holds  back  the  fluids  like  a 
sponge.  The  maximum  rate  of  secretion  is  also  reached  somewhat 
later  after  dinner,  sometimes  not  for  four  hours. 

After  mixed  meals  the  quantity  of  urea  is  more  than  doubled,  and 
the  phosphates  and  urates  are  increased  in  nearly  the  same  ratio. 
Proteid  foods  always  increase  the  output  of  urea,  urates,  or  uric  acid, 
while  vegetable  foods  increase  the  phosphates,  carbonates  and  sul- 
phates. 

In  diseases  characterized  by  nitrogenous  tissue  waste  the  latter  is 
reduced  by  giving  carbohydrates.  In  other  words,  the  carbohydrates 
spare  the  consumption  of  tissue  and  consequent  production  of  urates 
or  urea. 

Meat  and  albuminous  foods  in  general  tend  to  make  the  urine  more 
acid,  whereas  milk,  fruits,  and  vegetables  make  it  more  alkaline. 

Estimation  of  the  nitrogen  output  in  the  urine  affords  a  means  of 
determining  the  rate  and  extent  of  proteid  katabolism  within  the 
body.  This  at  least  is  the  modern  method,  regarded  as  the  best  by 
most  clinicians.  It  is,  however,  not  infallible,  as  criticised  by  F.  G. 
Benedict  and  E.  D.  Milner  in  a  record  of  recent  calorimeter,  "  Experi- 
ments on  the  Katabolism  of  Matter  and  Energy"  (U.  S.  Dept.  of 
Agriculture,  Bull.  175).  These  authors  say: 

"  Thus  an  excretion  of  a  certain  amount  of  nitrogen  in  a  24-hour 
period  from  7  A.  M.  to  7  p.  M.  is  assumed  to  indicate  that  during 
this  time  there  was  a  katabolism  of  a  corresponding  amount  of  pro- 
tein. This  assumption  is  open  to  serious  error.  In  the  first  place, 
it  is  not  true  that  all  the  nitrogen  of  food,  or  indeed  of  body  material, 
is  in  the  form  of  protein;  yet  by  assuming  that  the  excretion  of 
nitrogen  corresponds  to  the  katabolism  of  protein,  no  allowance  is 
made  for  the  possible  excretion  of  nitrogen  in  the  form  of  creatin,  uric 
acid,  hippuric  acid,  and  other  nitrogenous  bodies,  the  store  of  which 
may  be  considerably  altered  in  the  body  as  a  result  of  muscular  activ- 
ity, larger  quantities  of  water,  or  other  factors  as  yet  but  little  under- 


404  FOOD   DIGESTION 

stood.  Obviously,  then,  the  deduction  that  any  gain  of  nitrogen  by 
the  body  is  in  the  form  of  body  protein,  and  moreover  that  the  quan- 
tity of  nitrogen  multiplied  by  the  factor  6.0,  or  indeed  any  other  con- 
stant factor,  represents  the  total  amount  of  protein  gained,  is  not 
necessarily  final."  The  authors  quoted  assign  33.53  per  cent  of  ni- 
trogen in  the  organic  ingredients  of  urine  (i.  e.,  in  water  and  ash  free 
urine),  as  the  average  of  fifty-eight  rest  and  work  experiments.  In 
some  cases  the  percentage  was  slightly  higher  during  rest,  in  others 
during  work. 

TOBACCO  AND  FOOD 

The  effect  of  tobacco  upon  digestion  is  a  subject  very  closely  allied 
to  dietetics,  but  brief  mention  of  it  only  may  be  made  here.  Like 
alcohol,  undoubtedly  most  persons  are  better  without  it,  and  its  abuse 
is  well  known  to  disorder  digestion  through  the  action  of  nicotine 
upon  the  circulation,  and  especially  upon  the  vagus  nerve,  the 
branches  of  which  control  so  many  digestive  functions.  No  definite 
rules  can  be  formulated  for  the  use  of  tobacco  in  relation  to  meals 
beyond  those  suggested  by  the  fact  that  the  action  of  tobacco  is  always 
less  likely  to  prove  irritating  if  it  is  smoked  while  there  is  abundant 
food  in  the  stomach.  The  after-dinner  cigar  in  many  persons  pro- 
motes the  secretion  of  gastric  juice,  and  there  are  those  in  whom  a 
mild  cigar  after  breakfast  promotes  peristalsis  and  the  evacuation  of 
the  bowels.  If  there  be  any  tendency  to  indigestion  of  starchy  or  sac- 
charine foods,  it  is  usually  intensified  by  the  use  of  tobacco  in  any 
form. 

As  stated  elsewhere,  when  food  cannot  be  obtained  after  fatigu- 
ing exercise  or  a  forced  march,  the  moderate  use  of  tobacco  is  often 
found  temporarily  to  replace  it,  at  least  to  the  extent  of  lessening  the 
feeling  of  weariness.  (See  Substitutes  for  Food,  p.  316.)  Smoking 
immediately  before  meals  may  destroy  the  appetite  and  interfere  with 
the  digestion  of  the  food. 

FOOD  EQUIVALENTS  — FOOD  "PORTIONS" 

It  is  easy  to  compute  the  chemical  equivalents  of  foods  as  ana- 
lyzed outside  of  the  body.  It  is  quite  another  matter  to  compute 
them  with  accuracy  within  the  body.  Most  writers  upon  dietetics, 
however,  make  some  attempt  to  do  this,  and  the  following  data  may 
bo  accepted  as  approximately  correct:  One  pound  of  lean  beef  equals 
in  nutrient  value  three  eggs  or  two  pints  of  milk.  Boast  beef  con- 


FOOD  EQUIVALENTS 


405 


tains  about  the  same  protein  percentage  as  an  egg,  but  much  more 
fat.  One  pound  of  wheat  equals  3.5  pounds  of  potatoes. 

Of  common  cheese,  Parkes  estimated  that  "  about  half  a  pound 
contains  as  much  nitrogenous  substance  as  one  pound  of  meat,  and 
one-third  of  a  pound  as  much  fat."  It  requires  about  27  pounds  of 
milk  to  make  a  pound  of  butter,  and  about  10  pounds  to  make  a 
pound  of  cheese.  Von  Noorden  estimates  that  as  a  fat  former  7 
grams  of  fat  equals  9.3  grams  of  alcohol. 

Church  gives  the  following  table  of  the  estimated  equivalents  of 
foods  which  would  yield  the  necessary  daily  supply  of  nitrogen  if 
eaten  alone: 


Pounds. 

Ounces. 

Oatmeal     

1 

10 

Eersrs  . 

2 

Lean  beef   

2 

1 

Wheat  bread         

3 

13 

Potatoes     

24 

White  turnips    

54 

4 

Cow's  milk  

6 

8 

Rice    

3 

7 

To  obtain  the  necessary  daily  supply  of  carbon : 


Pounds. 

Ounces. 

Bacon     

1 

Cow's    milk      

8 

Wheat  bread  

2 

8 

EwgS    . 

5 

3 

Rice    

1 

11 

Turnips    

20 

Lean  beef  

6 

6 

Potatoes    

6 

6 

Food  "  Portions." —  For  convenience  in  estimating  the  caloric  value 
of  ordinary  meals,  food  may  be  measured  in  "  portions  "  or  "  help- 
ings." This  method  is  of  course  less  accurate  than  weighing,  but 
is  much  less  troublesome,  and  for  practical  purposes  often  suffices. 
Prof.  Irving  Fisher  gives  a  convenient  list  of  such  portions  as  follows : 

"A  'portion'  of  100  calories  may  be  ascribed  to  each  lamb  chop, 
or  its  equivalent  in  other  meat,  each  (large)  egg,  each  two-thirds  of 
a  glass  of  milk,  each  ordinary  potato,  large  slice  of  bread,  large 
banana,  ordinary  pat  or  square  of  butter,  shredded  wheat  biscuit  or  its 


406 


FOOD  DIGESTION 


equivalent  in  other  cereal,  eight  almonds,  half-dozen  English  walnuts, 
one  and  one-half  lumps  of  sugar,  etc." 

Most  persons  have  little  idea  of  the  weight  of  the  foods  they 
eat,  yet  the  usual  dietetic  tables  of  "  food  values  "  are  based  upon 
gram  measurements.  Following  is  a  list  of  approximate  weights 
of  foods  as  used  in  ordinary  "  portions  "  or  "  helpings  "  at  the  table 
by  the  average  person  in  health.  Of  course  such  an  estimate  cannot 
be  very  accurate,  yet  it  may  afford  interest. 

Quantities  of  Foods  for  Single  Meals. 


Grams. 

Ounces  (ap- 
proximate). 

Calories. 

Porridge   oatmeal    wheat,  cornmeal,  etc  

200 

6 

175 

Sugar  on  porridge   

10 

1A 

10 

Milk    (  one  tumblerful  )    

180 

6 

200 

Bread  (three  slices)    

100 

3 

200 

Butter  on  bread     

15 

1A 

120 

Steak   

50 

l2 

165 

Soup,  or  meat  broth  or  pur6e   

120 

4 

100-200 

Fish   

200 

6 

200 

Potatoes    

50 

11A 

60 

Green  vegetables   

100 

3 

50 

Peas,  beans  or  corn  

75 

2*4 

300 

Crackers  and  cheese  

75 

21A 

300 

Bread  or  Indian  pudding   

100 

3 

200 

Cocoa  (  one  cup  )    

150 

PART  VI 

THE  GENERAL  RELATIONS  OP  FOOD  TO  SPECIAL  DIS- 
EASES—DISEASES WHICH  ARE  CAUSED  BY 
DIETETIC  ERRORS 


THE   GENERAL  RELATIONS   OF  FOOD   TO   SPECIAL 

DISEASES 

THERE  are  two  methods  of  adapting  diet  for  the  sick:  First,  by 
merely  reducing  the  ordinary  quantity  of  food  for  health;  second,  by 
altering  the  quality  of  the  different  classes  of  foods,  and  reducing  the 
total  quantity  simultaneously  or  not,  as  required.  The  former  method 
is  simpler  and  less  troublesome,  and  for  some  few  cases  may  prove 
sufficient.  It  is  to  be  regretted  that  it  is  a  routine  method  adopted 
in  many  hospitals,  for  it  is  unscientific,  besides  being  often  wasteful 
and  radically  wrong.  The  second  method  presupposes  a  knowledge 
of  the  relations  of  diet  to  disease,  and  requires  careful  supervision. 
In  speaking  of  this  subject  Parkes  wrote :  "  It  is  certain  that  the 
physician  can  in  this  way  wield  a  great  power,  which,  if  less  striking 
than  that  obtained  more  rapidly  by  drugs,  is  yet  of  immense  mo- 
ment." 

The  same  aliments  which  in  health  produce  definite  results  in 
furnishing  energy  and  repairing  tissue  loss  may  fail  completely  in 
disease.  Such  is  the  case  in  diabetes  when  starches  become  not  only 
a  useless  but  a  harmful  food,  and  in  severe  albuminuria,  when  meats 
only  intensify  the  proteid  waste. 

In  the  majority  of  serious  diseases,  and  especially  of  acute  and 
febrile  diseases,  the  proteids  and  fats,  aside  from  those  of  milk,  become 
less  assimilable  than  the  carbohydrates.  Beneke  attributes  this  to  the 
fact  that  carbohydrates  are  respiratory  foods  —  i.  e.,  their  consump- 
tion results  in  the  production  of  carbon-dioxide  gas  and  water,  and 
the  elimination  of  carbon  dioxide  proceeds  in  disease  very  much  as 
in  health.  If  carbohydrates  are  not  furnished,  inanition  ensues,  for 
the  tissues  begin  to  consume  their  own  substances. 

There  are,  on  the  other  hand,  some  few  diseases,  such  as  tuber- 
culosis, chlorosis,  and  secondary  anaemia,  in  which  proteids  and  fats 
distinctly  may  be  required,  and  others  again  may  temporarily  de- 
mand a  purely  nitrogenous  diet. 

407 


408  RELATIONS   OF  FOOD   TO  SPECIAL  DISEASES 

Food  improper  in  quality  or  deficient  in  quantity  is  sure  to  be 
not  only  a  direct  source  of  disease,  but  indirectly,  by  lowering  the 
vitality  of  the  body,  it  leaves  it  an  easy  prey  to  epidemic  and  con- 
tagious diseases  of  every  sort.  This  was  strikingly  shown  during 
the  ravages  of  the  plague  in  the  Middle  Ages,  and  it  has  been  ap- 
parent in  the  history  of  all  recent  famines.  (See  Starvation,  p.  343, 
and  Famine,  p.  350.) 

The  important  relation  of  food  to  disease  in  regard  to  its  quantity 
and  composition,  as  well  as  the  frequency  and  method  of  its  ad- 
ministration, are  becoming  more  and  more  thoroughly  appreciated. 
This  is  owing  in  great  part  to  improved  methods  of  diagnosis  and 
to  modern  means  of  clinically  discriminating  between  different  kinds 
of  gastric  and  intestinal  indigestion.  It  is  also  due  to  an  increasing 
knowledge  of  the  chemistry  of  food,  of  food  preparation  by  cooking, 
and  of  "artificial  digestion,"  and  finally  to  better  analyses  of  waste 
products  in  urine  and  feces. 

There  is  still  much  difference  of  opinion  in  regard  to  the  best 
dietaries  for  certain  diseases,  such,  for  example,  as  gout  and  obesity, 
but  the  general  principles  of  dietetics  are  to-day  well  established  and 
more  widely  understood  and  practiced  than  ever  before,  and  starva- 
tion in  fevers,  like  excessive  venesection  and  similar  depleting  meas- 
ures, is  no  longer  carried  to  the  former  injurious  extreme.  There 
remains  much  to  be  learned  in  regard  to  dietetics;  and  the  great 
variations  in  digestive  power  which  are  encountered  in  individual 
cases  of  disease  and  in  personal  idiosyncrasy,  together  with  the  in- 
creasing varieties  of  foods  and  food  preparations,  make  the  relation 
of  diet  to  disease  a  constantly  broadening  subject,  the  importance 
of  which  cannot  be  overrated.  It  is  to  be  regretted  that  the  study  of 
dietetics  is  not  more  thoroughly  taught  as  a  necessary  part  of 
medical  education,  and  that  thorough  systematic  instruction  in  this 
practical  branch  of  science  is  omitted  from  the  curriculum  of  most 
medical  schools.  For  many  physicians  it  seems  far  easier  to  write 
a  brief  prescription  for  a  "  nerve  tonic "  or  cathartic  pill  than  to 
take  the  time  and  pains  to  state  in  writing  for  their  patients  a 
definite  dietary  which  in  very  many  cases  will  prove  an  invaluable 
adjunct  to  medicinal  treatment,  if  not  in  itself  a  curative  measure. 
Sometimes,  indeed,  they  appear  possessed  with  the  idea  that  the 
minutia?  of  dietetics  are  beneath  consideration,  whereas  in  reality, 
like  the  details  of  good  nursing,  they  are  most  important,  and  a 
careful  attention  to  them  and  a  close  interrogation  into  the  ordinary 
habits  of  the  patient  in  regard  to  his  daily  regimen  is  certain  of  ap- 
preciation and  of  beneficial  results. 


RULES  FOR  PRESCRIBING  A  DIETARY  409 

In  all  acute  febrile  diseases  and  in  all  so-called  "  wasting "  dis- 
eases in  which  there  is  faulty  assimilation  of  the  food,  the  digestive 
functions  are  impaired,  while  the  rapid  tissue  waste  increases  the 
need  for  nutriment  to  replace  it.  In  such  cases  enfeebled  digestive 
powers  must  be  taken  into  account,  and  while  endeavoring  to  sup- 
ply the  increased  demand  for  food,  every  effort  should  be  made  to 
relieve  the  alimentary  canal  of  unnecessary  labor  by  supplying  those 
preparations  which  will  yield  the  proper  degree  of  nutrition  and 
force  with  a  minimum  expenditure  of  digestive  energy.  Moreover, 
the  conditions  of  elimination  of  waste  materials  from  the  tissues 
must  be  studied  in  relation  to  the  composition  of  different  foods  in 
order  to  prevent  the  overworking  of  the  excretory  organs. 

It  may  be  asserted  that  there  is  almost  no  disease  of  long  dura- 
tion and  severity,  and  certainly  no  disease  accompanied  by  grave 
constitutional  disturbances,  the  course  of  which  cannot  in  a  measure 
be  controlled  or  benefited  by  thorough  study  of  the  nature  and  uses 
of  foods.  There  are  many  acute  ailments  in  which  undoubted  bene- 
fit is  derived  from  greatly  diminishing  or  altogether  withholding 
temporarily  the  consumption  of  food,  while  there  are  others  in  which 
forced  feeding  —  that  is,  increasing  the  quantity  of  food  to  the  utmost 
capacity  of  the  digestive  organs  —  is  a  necessity. 

The  general  relations  of  food  to  the  organism,  as  well  as  the  na- 
ture of  foods  and  the  processes  involved  in  their  preparation,  diges- 
tion, absorption,  and  assimilation,  have  received  full  consideration  in 
the  preceding  pages.  In  the  following  chapters  the  principles  briefly 
outlined  above  will  be  considered  in  detail  in  their  application  to 
individual  diseases.  At  the  risk  of  some  repetition,  it  has  been 
thought  best  to  make  the  dietetic  treatment  of  each  disease  as  com- 
prehensive as  possible  under  the  different  headings  considered,  and  to 
emphasize  its  value  by  a  brief  synopsis  of  the  more  important  symp- 
toms which  arise,  and  a  discussion  of  the  indications  to  be  met  by 
appropriate  dieting. 

GENERAL  RULES  FOR  PRESCRIBING  A  DIETARY 

1.  All  directions  should  be  made  specific,  and  in  writing. 

2.  The  patient's  previous  experience  with  the  foods  recommended 
should  be  investigated.     Often  a  supposed  difficulty  in  digestion  is 
due  to  errors  in  cooking  or  in  the  combination  with  other  foods. 

3.  The  patient  should  understand  that  no  one  food  is  curative, 
and  in  recommending  any  dietary,  however  limited,  regard  should 
be  had,  as  far  as  possible,  to  the  patient's  taste  and  to  stimulation 
of  the  appetite  by  acceptable  flavors. 


410  DISEASES   CAUSED   BY   DIETETIC   ERRORS 

4.  In  some  cases  it  is  preferable  to  have  the  patient  submit  his 
own  diet  list  for  correction. 

5.  In  some  cases  it  is  the  quantity  of  a  food  which  requires  re- 
duction rather  than  its  total  proscription. 

6.  The  relation  of  proper  intervals  of  rest,  exercise,  and  work  to 
meals  should  be  prescribed  as  definitely  for  those  who  are  not  bed- 
ridden as  the  diet. 

7.  The  daily  quantity  of  fluid  ingested  may  be  as  important  a 
consideration  as  the  regulation  of  food. 

8.  It  is  undesirable  to  prescribe  any  strict  dietary  for  too  long 
a  period,  or  for  an  indefinite  period,  otherwise  failure  of  appetite, 
inanition,  anaemia,  and  weakness  may  ensue.     If  a  strict  diet  is  bene- 
ficial, it  will  become  so  within  a  few  days,  or,  at  the  most,  within 
from  three  to  six  weeks.     The  question  of  its  continuance  or  modi- 
fication should  then  be  relieved,  for  in  some  cases  positive-  harm 
may  result  without  such  revision. 

9.  In   some   few  cases   radical  changes   in   diet   should  be   made 
gradually  at  the  outset,  but  in  the  majority  of  cases  immediate  change 
does  no  harm,  and  produces  more  prompt  results.     On  the  other 
hand,  a  return  to  the  normal  diet  should  be  made  by  slow  grada- 
tion. 

10.  It  is   most  undesirable  to  base  any  dietary  upon  too  rigid 
formulae  or  preconceived  "  systems."     Normal  idiosyncrasies  in  re- 
gard to  digestion  and  assimilation  are  numerous,  but  morbid  idiosyn- 
crasies in  disease  are  far  more  so;  hence,  each  important  case  sKould 
be  made  the  subject  of  independent  study  and  frequent  careful  ob- 
servation of  the  excreta  should  be  made. 

11.  In  cases  requiring  protracted  dieting  the  use  of  the  scales  in 
determining  the  body  weight  is  most  important. 

DISEASES  CAUSED  BY  DIETETIC  ERRORS 

While  the  course  of  the  majority  of  all  diseases  is  obviously  in- 
fluenced by  the  quantity  and  quality  of  the  food  eaten,  there  are 
particular  diseases  which  are  directly  caused  by  improper  diet.  This 
causative  relation  concerns: 

I.  Insufficient  food.  II.  Overeating  and  overdrinking.  III.  Food 
which  is  injurious  merely  because  the  ingredients  are  not  properly 
balanced.  IV.  Food  containing  parasites  or  their  embryos.  V. 
Food  containing  ptomaines.  VI.  Food  containing  other  poisons, 
grain  poisoning,  etc.  VII.  Food  containing  adulterants.  VIII. 
Food  containing  microorganisms.  IX.  Food  which  is  in  itself  whole- 


OVEREATING   AND   OVERDRINKING  411 

some,  but  against  which  personal  idiosyncrasy  exists.     X.  Alcohol  as 
a  food  and  poison. 

I.  Insufficient  Food 

The  general  effects  of  starvation  are  described  in  the  study  of 
the  proper  quantity  of  food  (p.  343).  The  effects  of  the  depriva- 
tion of  water  are  discussed  on  p.  42.  Insufficient  food  may  cause  the 
condition  of  marasmus,  and  is  an  important  agent  in  producing  some 
forms  of  anaemia.  (See  Marasmus,  and  Anaemia.) 

II.  Overeating  and  Overdrinking 

Both  overeating  and  overdrinking  may  be  (1)  temporary  —  that 
is,  the  result  of  an  occasional  debauch;  or  (2)  chronic. 

1.  Temporary  overeating  may  apply  to  the  excessive  consumption 
(a)  of  a  mixed  diet,  or  (&)  of  particular  articles  of  food.     The  former 
(a)  causes  dyspepsia,  or,  in  extreme  cases,  acute  gastroenteritis  and 
sometimes  fecal  impaction.     The  latter  (6)  may  also  cause  dyspepsia 
and  diarrhoea,  or  such  affections  may  be  produced  as  glycosuria,  from 
excessive  indulgence  in  candy  and  sweets,  and  acne  or  other  skin  dis- 
eases, from  the  too  liberal  consumption  of  fats. 

Temporary  overeating  at  one  or  two  meals  may  not  produce  any 
serious  effect,  but  if  the  excess  in  feeding  be  long  continued  a  variety 
of  ills  result,  attributable  directly  to  overloading  of  the  alimentary 
canal  and  to  the  accumulation  of  waste  matter  in  the  tissues,  and 
consequent  imperfect  oxidation  processes. 

The  excess  of  food  may  be  injurious  in  one  of  two  ways : 

First,  if  it  be  not  absorbed,  it  ferments  abnormally  in  the  alimen- 
tary canal.  There  is  a  limit  to  the  quantity  of  every  food  which 
can  be  digested  in  a  given  time;  beyond  this  the  food,  whether 
starches,  fats,  sugars  or  proteids,  may  decompose,  or  pass  away  un- 
altered. 

Second,  if  the  excess  be  absorbed  the  blood  is  overwhelmed,  and 
the  excretory  organs  are  overworked. 

The  inability  to  sing  with  precision  after  a  too  hearty  meal  is 
often  attributed  to  temporary  congestion  of  the  vocal  cords.  While 
this  is  observed  in  the  thickened  speech  of  alcoholism,  the  difficulty 
in  singing  caused  by  overeating  is  mainly  due  to  inability  to  regulate 
the  actions  of  the  diaphragm  and  other  respiratory  muscles  when 
the  stomach  is  greatly  distended. 

2.  Chronic   overeating  may  cause   such   diseases   or   diatheses   as 
obesity,  gout,  lithaemia,  oxaluria.  and  the  formation  of  renal,  vesical, 
and  hepatic  calculi.     It  is  very  certain  to  cause  congestion  of  the 


412  DISEASES  CAUSED  BY   DIETETIC   ERRORS 

liver  and  the  condition  known  as  "  biliousness,"  in  which  the  stom- 
ach and  intestines  are  engorged,  constipation  results,  the  tongue  is 
heavily  coated,  the  bodily  secretions  are  altered  in  composition,  the 
urine  especially  becoming  overloaded  with  salts,  the  liver  becomes 
congested,  and  finally  the  nervous  and  muscular  systems  are  affected, 
with  the  result  of  the  production  of  headache  and  feelings  of  fatigue, 
lassitude,  drowsiness,  and  mental  stupor. 

For  persons  leading  sedentary  lives,  excessive  consumption  of 
animal  food  is  more  injurious  than  that  of  vegetable  food,  for  the 
reasons  given  above,  although  obesity  is  more  favored  by  excess  in 
vegetable  diet  and  sweets.  Proteid  foods,  requiring,  as  they  do,  a 
large  consumption  of  oxygen  for  their  complete  combustion  and  re- 
duction to  urea  and  allied  products,  produce  forms  of  waste  matter 
in  the  system  which  are  more  deleterious  than  the  carbohydrates  that 
are  converted  into  water  and  carbonic  acid,  and  are  more  easily 
eliminated.  It  is  for  this  reason  that  defective  proteid  katabolism 
alters  the  composition  of  the  blood  and  paves  the  way  for  disorders 
of  nutrition,  and  especially  hepatic  and  renal  disease. 

The  presence  of  intestinal  roundworms  and  tapeworms  may  give 
rise  to  overeating,  though  this  by  no  means  always  follows. 

Overeating  is  apt  to  be  carried  to  an  injurious  extent  by  the 
half-starved  poor  if  they  have  sudden  access  to  plenty,  and  by  con- 
valescents from  typhoid  fever. 

Bulimia  is  a  form  of  perverted  sensation,  causing  inordinate 
craving  for  food,  which  is  described  on  page  370. 

Overeating,  especially  among  the  well-to-do,  is  the  commonest 
dietetic  error,  and  there  are  some  examples  of  alcoholism  in  which 
the  desire  for  drink  is  aroused  and  fostered  by  previous  excesses  in 
eating. 

Overdrinking,  except  of  alcohol  (which  is  considered  under  the 
heading  of  Alcoholism,  p.  438),  is  not  common,  and  is  mainly  con- 
fined to  the  excessive  consumption  of  tea  and  coffee,  which  results  in 
insomnia,  cardiac  palpitations,  and  various  neuroses  (see  pages  250, 
255).  Dilatation  of  the  stomach  has  been  attributed  in  some  cases  to 
overindulgence  in  mineral  waters,  but  such  cases  are  very  unusual. 
Polyuria  and  diabetes  insipidus  have  also  been  ascribed  to  the  ab- 
normal consumption  of  fluids,  but  without  strong  proof.  Excessive 
use  of  milk  as  a  beverage  usually  results  in  "  biliousness  "  and  constipa- 
tion, but  for  the  reason  that  it  is  really  a  solid  food  —  that  is,  it  be- 
comes such  immediately  on  entering  the  stomach,  owing  to  the  forma- 
tion of  tough  coagulrip.  Excessive  consumption  of  beer  may  cause 
dilatation  of  the  stomach. 


FOOD   CONTAINING  PARASITES  413 

III.  Food  Which  is  Injurious  Merely  Because  the  Ingredients 

are  not  Properly  Balanced 

Such  diet  may  produce  anaemia,  from  lack  of  meat  or  other  animal 
food;  scurvy,  from  preponderance  of  salt  meat  and  fish  and  lack 
of  fresh  fruits  and  vegetables;  rickets  and  marasmus,  from  errors  in 
infant  feeding,  such  as  excess  of  amylaceous  and  lack  of  animal  food, 
necessary  salts,  etc. ;  acne,  or  eczema,  from  food  too  rich  in  fats ;  con- 
stipation, from  a  too  nutritious  and  concentrated  diet;  gout  from 
various  dietetic  errors.  • 

IV.  Food  Containing  Parasites  or  their  Embryos 

Food  sometimes  serves  as  the  mediuin  for  the  introduction  of  para- 
sites or  their  embryos,  such  as  various  species  of  tapeworm,  the 
roundworm,  echinococcus,  and  trichina. 

In  many  cases  the  source  of  infection  is  found  in  the  consumption 
of  raw  or  imperfectly  cooked  swine  flesh  and  other  meats  used  in 
the  manufacture  of  sausages  and  similar  preparations  which  are  care- 
lessly handled  and  come  in  contact  with  the  viscera  of  the  animals 
in  which  the  parasites  or  embryos  reside  in  some  intermediate  stage 
of  development.  Another  possible  source  of  infection,  especially  of 
intestinal  worm  larvae,  is  in  the  excrement  of  animals,  which  is  per- 
mitted to  pollute  raw  vegetables  growing  upon  the  ground.  Manure 
is  freely  spread  about,  and  dogs  infested  with  worms,  or  a  casual  pig 
roaming  at  large  in  a  vegetable  garden,  may  contaminate  by  their 
feces  such  vegetables  as  grow  low  upon  the  ground  and  are  usually 
eaten  raw,  as  lettuce,  celery,  etc.  Fortunately,  this  is  by  no  means 
a  common  source  of  infection,  but  it  is  well  to  remember  that  several 
cases  of  infection  have  been  traced  definitely  to  such  a  source,  and 
this  explains  the  occasional  presence  of  tapeworms  in  people  who 
never  eat  raw  meats,  ham,  or  sausage,  or  the  flesh  .of  swine  in  any 
form.  No  domestic  animal  should  ever  be  allowed  to  roam  in  a 
vegetable  garden.  Other  varieties  of  parasites  or  their  larvae  may  oc- 
casionally be  introduced  with  the  food  or  water,  such,  for  example,  as 
the  Dracunculus  medinensis,  which  produces  the  Guinea- worm  disease, 
or  Draconiiasis,  the  larvas  of  which  are  sometimes  swallowed  in  drink- 
ing water  by  the  natives  of  parts  of  Africa  and  the  East  Indies. 

INTESTINAL  WOKMS 

The  presence  of  intestinal  worms,  such  as  the  roundworm,  Ascaris 
lumbricoides,  and  various  species  of  cestodes  or  tapeworms,  requires 
no  special  dietetic  care  beyond  the  preventive  treatment  of  avoiding 


414  DISEASES  CAUSED  BY   DIETETIC   ERRORS 

raw  or  imperfectly  cooked  flesh,  and  if  it  has  been  eaten,  submitting  to 
a  period  of  starvation  for  twenty-four  hours,  in  order  that  the  in- 
testine may  be  emptied  completely  of  food  before  an  anthelmintic  is 
given,  so  that  it  may  more  certainly  reach  the  worms. 

There  are  two  principal  varieties  of  tapeworm  in  man,  besides  four 
or  five  others,  which  are  very  rarely  present  in  the  intestine,  being  de- 
rived from  the  lower  animals  through  habits  of  filth  or  carelessness 
in  preparing  food. 

Of  these  two  varieties,  the  commonest  in  this  country  is  the  Tcenia 
saginata,  or  mediocanellata;  the  other,  the  pork  tapeworm,  or  Tcenia 
solium,  is  more  often  found  in  Europe  and  Asia.  The  larval  stages 
of  Tcenia  solium  and  Tcenia  echinococcus  also  are  observed  in  man, 
and,  according  to  C.  W.  Stiles,  one-half  the  persons  affected  by  the 
latter  die  within  five  years.  H.  0.  Sommer  has  collected  100  cases 
of  echinococcus  (hydatid)  disease  in  this  country.  The  larvae  are 
derived  from  the  dog.  "With  the  recent  increase  in  Italian  immigra- 
tion, cases  have  become  not  infrequent  among  these  foreigners.  They 
are  accompanied  by  a  form  of  pernicious  anaemia. 

The  Tcenia  mediocanellata  is  a  segmented  worm,  having  a  large 
square  head  presenting  four  suckers,  by  which  it  maintains  its  hold 
upon  the  intestinal  mucosa  without  the  aid  of  booklets.  The  seg- 
ments increase  very  slowly  in  size  behind  the  head,  and  finally 
attain  a  breadth  of  eight  to  ten  millimeters  and  a  length  of  seventeen 
to  eighteen  millimeters,  while  the  whole  animal  may  reach  a  length  of 
twenty  feet,  or  even  become  longer  than  the  intestine.  Fragments 
of  the  worm  are  constantly  breaking  off,  compressed  by  the  waste 
matter  of  the  food,  and  with  it  are  swept  out  of  the  gut.  The 
larvas  live  in  swine. 

The  Tcenia  solium  is  not  so  long  as  the  mediocanellata,  measuring 
usually  from  six  to  twelve  feet.  The  head,  which  is  quite  small, 
presents  four  suckers  and  several  minute  hooks,  which  enable  the 
animal  to  secure  a  firm  hold  upon  the  mucous  membrane.  Behind 
the  head  are  a  series  of  segments,  many  hundred  in  number,  con- 
stituting the  body.  They  gradually  increase  in  size,  and  the  larger 
ones  contain  male  and  female  organs  of  generation,  each  segment 
being  supplied  with  both  varieties.  The  larger  segments  attain  a 
size  of  seven  to  eight  millimeters  by  ten  millimeters.  Each  mature 
segment  contains  an  enormous  number  of  ova  —  often  several  thou- 
sand—  and  in  about  three  months,  when  the  worm  has  reached  its 
full  size,  the  segments,  which  are  narrower  and  smaller  than  those  of 
mediocanellata,  are  continually  breaking  off  and  passing  out  with  the 
feces.  Pis^s  oat  the  ova.  and  digest  them.  The  ova  consists  of  shells 


FOOD  CONTAINING  PAEASITES  415 

which  contain  minute  embryos  with  six  hooklets.  The  embryos  make 
their  way  into  the  viscera  or  muscles  of  the  animal,  where  they  lodge 
and  develop  to  form  the  Iarva3  or  cysticerci,  called  also  "  measles." 
If  the  measled  hog  meat  is  eaten  by  man,  and  imperfectly  cooked, 
the  cysticerci  develop  with  the  intestinal  worms  above  described. 

The  worms  infest  man  at  all  ages,  from  early  childhood  up.  They 
may  cause  no  symptoms,  but  sometimes  give  rise  to  a  ravenous  ap- 
petite, as  they  interfere  with  intestinal  digestion  and  absorption. 
They  occasionally  excite  reflex  nervous  disturbances.  Their  presence 
is  made  certain  by  the  finding  of  either  the  ova  or  the  complete  seg- 
ments in  various  lengths  in  the  stools. 

The  dibothriocephalus  latus  is  another  form  of  tapeworm,  rarely 
imported  into  this  country  by  natives  of  Poland,  who  ingest  the  ova 
which  infest  certain  species  of  fish,  like  the  sturgeon,  which  they 
eat  raw.  The  worm  produces  a  toxin  in  the  intestine,  which  being 
absorbed,  produces  a  pernicious  anemia  with  hemorrhages. 

Treatment. —  The  patient  infested  by  a  tapeworm  should  be  put 
upon  very  short  rations  for  two  days,  during  which  time  the  bowels 
must  be  well  emptied.  The  evening  before  giving  the  vermifuge  the 
patient  should  take  a  light  supper  of  bread  and  milk  or  a  sandwich, 
and  that  night  a  brisk  cathartic.  It  is  best  to  give  the  taeniacide 
the  next  morning  fasting.  By  this  means  the  intestines  become  al- 
most empty,  and  the  head  of  the  worm  is  left  unprotected,  so  that 
whatever  remedy  is  used  to  kill  it  will  make  it  loosen  its  hold. 
Another  laxative  may  be  given  a  few  hours  later,  and  if  the  patient 
eats  bulky  food,  such  as  Graham  bread  and  potatoes,  for  a  day  or  two, 
and  keeps  the  bowels  active,  the  worm  may  be  dislodged  and 
crowded  out.  The  stools  should  be  floated  in  water  and  closely  ex- 
amined for  the*  head,  for  if  this  is  not  obtained  the  worm  is  sure 
to  grow  again  in  three  or  four  months.  There  are  many  taeniacides. 
One  of  the  least  disagreeable  and  most  efficient  when  properly  ad- 
ministered is  pumpkin  seed.  The  seeds  should  be  husked,  and  three 
ounces  may  be  pounded  in  a  mortar,  mascerated,  mixed  with  honey 
into  a  paste,  and  eaten  spread  like  jam  upon  a  thin  slice  of  bread. 

TRICHINOSIS  (Trichiniasis) 

Etiology. —  Trichinosis  is  a  parasitic  disease  produced  by  the  em- 
bryos of  a  worm,  the  Trichina  spiralis,  which  work  their  way  into 
the  voluntary  muscles  and  there  become  embedded.  Among  the 
parasites  liable  to  be  eaten  with  raw  meats  this  one  is  by  far  the 
most  fatal,  although  I  have  seen  many  mild  cases  of  infection.  The 
habitat  of  the  adult  worm  is  the  small  intestine.  The  parasites  have 


416  DISEASES  CAUSED   BY   DIETETIC   ERRORS 

the  following  appearance:  The  adult  male  measures  1.5  millimeter 
in  length;  the  female  is  from  two  to  two  and  a  half  times  as  long. 
The  embryo  is  0.6  to  1.0  millimeter  in  length,  and  when  at  rest,  en- 
capsulated in  the  muscle,  is  coiled  in  a  spiral.  It  has  a  blunt  tail 
and  a  sharp  head.  The  adult  male  has  two  small  projections  from 
the  caudal  end.  The  ovoid  capsule  first  appears  translucent,  but 
later,  from  the  deposition  of  salts  of  lime,  it  becomes  opaque. 

Infection  in  man  is  caused  by  the  eating  of  ham  and  pork  from 
hogs  whose  bodies  contain  the  parasite.  Among  these  animals  it  is 
of  quite  frequent  occurrence.  It  is  also  spread  through  the  agency 
of  rats,  which  are  eaten  by  hogs  (Dock). 

Natural  History  of  the  Parasite. —  After  eating  flesh  which  con- 
tains the  embryos  the  process  of  digestion  dissolves  their  capsules, 
and  they  are  liberated,  passing  into  the  small  intestine,  where,  with 
the  presence  of  the  favorable  condition  of  warmth,  moisture,  and 
food,  they  reach  their  adult  growth  in  from  three  to  six  days.  Eapid 
reproduction  takes  place  in  the  intestine,  and  the  number  of  young 
produced  by  a  single  female  worm  varies  up  to  at  least  a  thousand. 
In  a  week  or  more  after  the  ingestion  of  the  parasites  the  newly 
developed  embryos  pass  out  through  the  intestinal  wall  and  mesen- 
tery, seeking  the  muscles,  which  they  enter;  they  then  work  their 
way  through  the  connective  tissues  between  the  fasciculi  or  the  sepa- 
rate muscle  fibers,  and  finally  enter  the  latter,  where  a  fortnight's 
further  development  produces  the  complete  muscle  form. 

The  observations  of  Askanazy  point  to  the  conclusion  that  the 
adult  female  deposits  the  embryos  within  the  walls  of  the  intestinal 
villi,  not  setting  them  free  in  the  intestine,  as  originally  supposed. 
From  the  villi  they  penetrate  the  muscles,  as  above  stated. 

Thornbury  reported  at  the  Buffalo  Academy  of  Medicine  the 
results  of  analysis  of  500  cases  of  infected  swine.  In  these  animals 
the  parasite  was  found  in  the  diaphragm  400  times,  in  the  loin  290 
times,  and  in  the  neck  170  times:  "The  point  of  predilection  there- 
fore appears  to  be  the  diaphragm.  This  is  explained  by  its  close 
proximity  to  the  digestive  tract,  from  which  the  trichinae  primarily 
bore."  In  three  cases  in  man  which  he  examined  the  trichinae  were 
found  principally  in  the  extremities,  "one  microscope  slide  from 
the  biceps  of  an  arm  containing  fifty  of  the  parasites/'  They  were 
also  present  in  the  diaphragm,  intercostal  and  abdominal  muscles. 

The  embryos,  when  lodged  in  the  muscle  fibers,  act  as  foreign 
bodies  or  irritant?  and  excite  an  interstitial  myositis  with  the  forma- 
tion of  a  capsule  around  each  embryo.  One  embryo  may  be  lodged 
in  a  single  capsule.  Once  within  the  muscle  fibers,  embryos  remain 


FOOD   CONTAINING   PAKASITES 

without  change  until  the  capsule,  the  completion  of  which  requires 
about  six  weeks,  is  in  some  way  destroyed.  After  formation  of  the 
capsule  a  precipitation  of  lime  salts  occurs  slowly  within  it  for  four 
or  five  months.  The  embryos,  thus  securely  protected  in  a  strong 
envelope,  may  retain  their  vitality  for  many  years,  but  the  worms 
themselves  not  infrequently  become  calcified.  Other  animals  besides 
hogs  may  harbor  this  parasite,  among  which  are  the  rat,  cat,  mouse, 
and  fox. 

Prophylaxis. —  The  prevention  of  trichinosis  should  consist  in  the 
more  careful  feeding  of  swine  upon  grain  instead  of  offal,  and  for 
man  the  only  absolute  prevention  is  the  extremely  thorough  cooking 
of  all  swine  flesh,  for  a  temperature  of  140°  F.  is  fatal  to  the  em- 
bryos. Pickling  or  corning  meat  or  smoking  ham  and  bacon  are  not 
necessarily  fatal  to  them. 

"  In  the  usual  curing  solutions  trichina  are  killed  within  six 
weeks  in  thin  pieces  of  meat,  but  in  thick  pieces  they  can  exist  as, 
long  as  four  months"  (Dock). 

The  presence  of  the  parasites  in  countless  numbers  in  the  flesh 
of  the  hog  may  give  rise  to  no  symptoms  of  any  kind  in  the  animal, 
and  it  is  this  fact  which  makes  the  eating  of  raw  ham,  pork,  and 
sausages  particularly  dangerous  unless  the  meat  of  the  animals  killed 
has  been  subjected  to  a  searching  microscopic  examination.  It  is  the 
safest  rule  never  to  eat  such  meats.  The  difficulty  of  detecting 
the  parasite  in  the  hog  is  considerably  increased  by  the  fact  that  the 
calcification  is  very  much  slower  than  it  is  in  man,  so  that  the  worms 
are  more  readily  overlooked. 

Frequency. —  Cases  of  trichinosis  are  often  reported  in  this  coun- 
try chiefly  among  the  Germans,  Poles  and  other  foreigners,  whose 
fondness  for  raw  ham  and  a  variety  of  sausages  is  well  known.  Osier 
reported  the  finding  of  456  cases,  including  122  deaths  recorded  in 
the  United  States.  I  have  seen  more  than  thirty  cases.  Many  per- 
sons are  often  simultaneously  affected  from  eating  the  meat  of  the 
same  animal,  thus  giving  the  disease  the  character  of  an  epidemic. 

Symptoms. —  The  symptoms  vary  with  the  number  of  parasites 
eaten.  If  very  few  are  ingested,  the  embryos  are  not  reproduced  in 
sufficient  number  to  give  rise  to  any  symptoms.  Usually,  however, 
they  are  well  marked,  and  embrace  a  stage  of  gastrointestinal  irrita- 
tion followed  by  systemic  infection.  The  patient,  three  or  four  days 
after  eating  raw  pork  or  ham,  suffers  from  more  or  less  severe  ab- 
dominal cramps,  with  anorexia,  vomiting,  and  diarrhoea.  The  latter 
occasionally  becomes  severe.  General  muscular  prostration  is  also 
present,  and  there  may  be  chills.  In  a  number  of  cases  the  gastro- 
29 


418  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

intestinal  symptoms  may  not  be  severe  enough  to  attract  attention, 
and  the  first  symptoms  are  those  of  general  infection,  which  develop 
at  the  commencement  of  the  second  week.  There  is  an  increase  of 
temperature,  which  reaches  103°  or  104°  F.,  of  an  intermittent  or 
remittent  character.  As  soon  as  the  embryos  have  penetrated  the 
muscles  they  give  rise  to  local  pain  and  tenderness,  accompanied  by 
swelling  and  tension. 

These  symptoms  increase  in  intensity,  and  general  oedema  is  apt 
to  follow,  which  may  appear  first  in  the  eyelids  and  elsewhere  in  the' 
face.  When  certain  muscles  are  implicated  more  serious  symptoms 
may  result.  *If  the  diaphragm  is  invaded  or  other  muscles  of  respi- 
ration, there  may  be  extreme  or  even  fatal  dyspnoea.  If  the  parasites 
reach  the  muscles  of  the  face,  jaw,  and  pharynx,  mastication  and  de- 
glutition become  difficult  or  impossible.  There  is  more  or  less  itching 
and  burning  of  the  skin  and  perspiration.  Urticaria  has  been  ob- 
served; anaemia  and  a  marasmic  condition  eventually  develop  in  a 
majority  of  cases,  and  marked  eosinophilia  amounting  to  GO  or  40 
per  cent  is  observed  in  the  blood  in  this  type  as  it  is  in  certain  other 
varieties  of  intestinal  parasitic  disease.  There  is  comparatively  little 
disturbance  of  the  nervous  system,  and  patients  are  usually  conscious 
until  the  time  of  death,  but  in  some  instances  a  typhoid  state  super- 
venes with  delirium. 

Prognosis. —  Many  cases  are  fatal.  Mild  cases  may  end  in  recov- 
ery within  a  fortnight.  In  severe  cases  in  which  there  has  been 
great  prostration  and  emaciation  convalescence  is  retarded  for  many 
weeks. 

Children  are  more  apt  to  recover  than  adults,  but  the  outlook 
depends  chiefly  upon  the  number  of  parasites  ingested.  Cases  pre- 
senting severe  diarrhoea  are  more  likely  to  end  favorably,  probably 
because  some  of  the  parasites  are  eliminated  in  this  manner. 

Mortality. —  The  greatest  mortality  occurs  between  the  fourth  and 
sixth  week.  The  causes  of  death  may  be  exhaustion  from  choleraic 
discharges,  dyspnoea,  and  inability  to  swallow. 

Diagnosis. —  The  most  valuable  features  in  determining  the  diag- 
nosis are  the  extreme  tenderness  to  pressure  of  the  muscles,  their 
swollen  condition,  the  eosinophilia  and  the  general  oedema  and  dysp- 
noea. Under  cocaine  anaesthesia  a  small  piece  of  muscle  may  be 
excised  from  the  arm  or  thigh  for  microscopic  examination.  On 
searching  the  stools  for  the  parasites,  they  may  be  found  with  a 
low-power  lens  as  glistening  threads. 

Treatment. —  The  basis  of  treatment  is  at  once  to  evacuate  the 
alimentary  canal,  providing  the  fact  of  eating  the  infected  meat  is 


419 

known  within  a  day  or  two.  Diarrhoea  should  not  be  checked.  If 
constipation  exists,  a  strong  purgative  of  calomel  and  jalap  or  castor 
oil  should  be  administered.  When  systemic  symptoms  develop,  the 
treatment  should  be  purely  symptomatic,  because  there  is  no  known 
remedy  which  will  reach  and  destroy  the  trichinae.  Every  effort 
should  be  made  to  support  the  strength  of  the  patient  until  the  em- 
bryos have  become  encysted,  after  which  the  acute  symptoms  will 
subside  of  themselves. 

V.  Food  Containing  Ptomaines 

Ptomaines  are  substances  resembling  alkaloids  which  are  formed 
in  the  alimentary  canal  by  the  decomposition  or  putrefaction  of 
proteid  foods.  They  may  also  form  in  such  food  outside  of  the 
body.  This  decomposition  is  the  result  of  the  action  of  certain 
microorganisms  simultaneously  first  described  by  Gautier  in  France 
and  Selim  in  Bologna.  Many  microorganisms  flourish  in  beef  juice, 
milk,  and  various  solutions  of  proteids;  and  in  the  alimentary  canal, 
when  such  food  is  taken,  all  the  most  favorable  conditions  are  pres- 
ent for  the  development  of  toxic  substances.  When  toxigenic  germs 
are  ingested,  their  toxins  are  readily  absorbed  by  the  intestinal  mucosa, 
and  it  is  probable  that  ptomaine  poisoning  would  occur  much  oftener 
were  it  not  that  the  liver,  acting  as  it  does  as  a  "  gateway  "  for  the 
admission  of  nutritive  material  for  the  body,  is  capable  of  destroy- 
ing many  poisons  which  enter  it  from  the  intestines  through  the 
branches  of  the  portal  vein. 

This  fact  is  confirmed  through  the  effect  of  putrefying  meat,  which 
in  very  small  quantities  may  not  produce  severe  gastrointestinal  symp- 
toms or  constitutional  disturbances,  and  yet  if  inoculated  through  a 
cut  in  the  finger  may  cause  symptoms  of  a  violent  septic  character. 

Ptomaines  may  be  developed  from  a  variety  of  foods,  but  the  prin- 
cipal ones  from  which  poisoning  from  time  to  time  occurs  are  spoiled 
meat,  milk,  shellfish,  and  fish. 

POISONING  BY  MEAT  OR  GAME 

When  meat  has  been  kept  too  long  exposed  to  the  air,  or  when 
contaminated  in  an}'  manner  with  putrefactive  bacteria,  it  is  unfit  for 
food,  yet  if  thoroughly  cooked  it  may  not  be  poisonous  necessarily. 
This  is  the  case  with  "  high  "  game.  The  bacilli  especially  associated 
with  meat  poisoning  are  classed  in  three  groups.  (1)  The  anaerobic 
bacillus  botulinus  causing  through  its  toxin  the  condition  of  "  botulis- 
mus,"  derived  most  often  from  eating  tainted  ham,  sausage,  game, 
etc.,  which  has  not  been  heated  above  70°  C.,  at  which  temperature 


420  DISEASES  CAUSED  BY   DIETETIC   ERRORS 

the  organism  is  killed.  (2)  Bacilli  of  the  proteus  group,  putrefac- 
tive bacteria  developing  in  wholesome  food.  The  bacillus  butyricus 
of  van  Ermenghem  is  an  especially  active  agent.  (3)  Bacilli  of 
the  hog  cholera  group  and  especially  the  bacillus  enteritidis  of 
Gartner,  and  a  series  of  paratyphoid  bacilli.  Cattle  and  swine 
slaughtered  while  having  acute  interitis  constitute  sources  of  infec- 
tion from  these  organisms  when  their  flesh  is  eaten  by  man,  or  the 
milk  of  such  cows  is  consumed. 

Dangerous  and  not  infrequently  fatal  cases  of  systemic  poisoning 
by  meat  ptomaines  result  from  eating  sausages,  pork  pie,  ham,  meat 
juice,  beef,  head-cheese,  mutton,  or  veal. 

Eichard  (Diseases  of  Modern  Life)  reports  a  fatal  case  of  poison- 
ing from  eating  tainted  hare.  The  victim  had  had  a  small  ulcer  be- 
neath the  tongue  for  some  time,  which  became  gangrenous  after  eat- 
ing the  meat,  and  which  was  the  undoubted  source  of  inoculation. 
Two  hundred  and  ninety-one  severe  cases  of  meat  poisoning,  one 
of  which  ended  fatally,  developed  upon  the  U.  S.  transport  City  of 
Rio  de  Janeiro,  in  1899,  while  proceeding  from  Honolulu  to  Manilla. 

Putrefactive  changes  may  have  already  begun  in  meat  although 
this  may  not  be  apparent  by  an  altered  taste. 

Sausage  poisoning  is  called  botulism  or  allantiasis. 

It  is  a  curious  fact  that  certain  persons  have  great  toleration  for 
tainted  meats.  Tissier  and  Martally  ate  rotten  meat  as  an  experiment, 
without  disagreeable  effect^  but  this  result  was  exceptional.  Among 
civilized  races,  and  especially  in  England,  the  use  of  "  high  "  game  and 
mutton  is  much  less  in  vogue  at  present  than  formerly,  but  the  Eskimos 
and  many  savage  tribes  in  Africa  eat  with  relish,  and  digest  well,  de- 
composing meat  the  mere  odor  of  which  nauseates  a  white  man. 
Bishop  Colenso  stated  that  among  the  Zulus  of  Natal  the  synonym 
for  heaven  is  "  ubomi"  which  means  "maggoty  meat."  The  natives 
of  Siam  and  Cambodia  prefer  to  keep  their  fish  until  it  has  begun 
to  putrefy.  In  some  parts  of  China  Dutrid  eggs  several  months  old 
are  enjoyed  as  a  delicacy. 

Swine  flesh  rapidly  decomposes,  when  the  various  processes  of 
drying,,  smoking,  and  salting  still  leave  it  unfit  for  food.  On  the 
contrary,  drying  and  smoking  affect  the  superficial  layers  only,  while 
the  inner  portion  furnishes  a  culture  medium  for  bacilli.  Gluck- 
mann  has  reported  a  case  of  poisoning  by  the  Bacillus  proteus  vulgaris 
from  eating  "  cured  "  ham. 

The  meat  of  very  young  animals  should  never  be  eaten,  and  the 
sale  of  young  or  "  bob  "  veal  two  or  three  weeks  old  is  prohibited 
by  law.  It  is  indigestible,  innutritions,  and  readily  decomposes. 


FOOD  CONTAINING  PTOMAINES  421 

Of  the  dangers  of  poisoning  from  canned  foods,  Wiley  says: 
"  Bacterial  action  seldom  occurs  in  the  can  without  bursting  it  or 
rendering  it  unsalable.  Ptomaines  may,  however,  develop  where  the 
canned  food  is  allowed  to  stand  for  some  time  after  opening,  though 
this  is  unlikely  in  the  case  of  preserved  vegetables." 

Canned  beef  should  be  eaten  promptly  after  opening,  for  it  is 
liable  to  spoil  within  a  few  hours,  especially  in  tropical  climates. 
Severe  gastroenteric  disorders  may  arise,  from  eating  such  spoiled 
meat,  and  epidemics  of  such  poisoning  have  been  observed  in  a 
French  garrison  at  Tours  (1898),  among  the  British  troops  in  South 
Africa  (1900),  and  among  our  own  troops  in  Cuba  (1899).  In  the 
latter  case  much  public  scandal  arose  in  connection  with  this  subject, 
and  from  the  further  fact  that  manufacturers  do  not  always  resist 
the  temptation  to  can  meats  of  inferior  quality,  or  which  may  be 
already  partially  decomposed,  especially  when  hurried  demands  for 
canned  goods  are  made  to  meet  the  exigencies  of  warfare.  At  the 
commencement  of  the  Spanish-American  "War,  in  1898,  7,000,000 
pounds  of  canned  roast  beef  were  purchased  by  the  Commissary  De- 
partment for  use  by  the  United  States  soldiers.  When  very  large 
cans  are  used  for  large  pieces  of  meat  it  may  be  unevenly  cooked  and 
contain  decomposing  areas  in  the  center. 

Symptoms. —  The  symptoms  of  meat  poisoning  from  these  various 
substances  are  substantially  the  same  in  each  case,  being  those  of 
serious  gastrointestinal  irritation,  and  in  severe  cases  they  are  accom- 
panied by  dangerous  collapse.  The  symptoms  may  follow  almost 
immediately  or  after  an  interval  of  four  or  five  or  more  hours.  The 
former  is  much  better  for  the  patient,  for  the  sooner  vomiting  and 
diarrhcea  relieve  the  alimentary  canal  of  the  toxigenic  material,  the 
greater  the  chance  of  recovery.  The  symptoms  usually  begin  with 
suddenness  and  violence,  but  they  may  be  preceded  by  malaise,  nau- 
sea, lassitude,  and  mild  abdominal  cramps.  The  sudden  onset  is 
ushered  in  by  rigors  with  vertigo  or  faintness,  or  violent  headache. 
Exceptionally  there  is  dyspnoea,  and  there  may  be  cold  perspiration 
and  sudden  severe  pains  in  the  epigastrium  or  in  the  thorax,  es- 
pecially between  the  shoulders.  Intense  thirst  has  also  been  ob- 
served. Soon  after  one  or  more  of  these  symptoms  have  appeared 
there  is  violent  colicky  pain  in  the  bowels,  accompanied  by  retch- 
ing and  vomiting,  sometimes  hpematemesis,  and  profuse  watery 
diarrhoea.  There  is  an  extreme  degree  of  muscular  prostration  which 
comes  on  suddenly  and  prevents  the  patient  from  standing.  It  may 
be  due  to  the  abdominal  pain,  but  also  occurs  independently.  The 
tongue  is  dry  and  coated  with  a  thick  brownish-yellow  fur  on  the 


422  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

dorsum,  but  the  margins  are  of  a  bright  red  with  distinct  papillae. 
Fever  is  usually  present,  and  the  temperature  may  rise  to  103.5 3  or 
104°  F.,  although  the  skin  may  feel  cold  and  moist.  The  pulse  is 
accelerated  and  the  rate  may  reach  130  or  140. 

Occasional  symptoms  noted  are  severe  cramps  in  the  legs  and 
arms,  convulsive  twitching  of  the  muscles  of  the  face  and  hands, 
stiffness  in  the  joints,  and  various  abnormalities  of  sensation,  such 
as  numbness,  tingling,  and  flashes  of  heat  and  cold  in  the  extremities. 
There  may  be  also  drowsiness,  photophobia,  and,  in  the  worst  cases, 
insomnia,  nervous  excitement,  or  mild  delirium.  If  the  poison  re- 
sult fatally,  prostration  increases,  the  pulse  grows  rapid  and  feeble, 
the  watery  evacuations  are  uncontrollable,  and  rapid  emaciation  en- 
sues. The  patient  becomes  cyanotic  and  passes  into  a  state  of  collapse 
resembling  that  of  the  last  stage  of  cholera. 

The  poisoning  presents  all  degrees  of  severity,  depending  on  the 
amount  of  the  tainted  food  which  has  been  taken,  the  nature  of  the 
putrefactive  process,  and  the  condition  of  the  alimentary  canal  as  to 
food  content  at  the  time.  In  mild  cases,  more  or  less  abdominal 
pain,  vomiting,  diarrhoea,  and  headache,  with  slight  prostration,  are 
the  only  symptoms.  In  the  grave  cases,  if  convalescence  follows  the 
attack,  it  is  prolonged,  and  the  weakness  of  the  patient  may  be  fully 
as  great  as  after  some  of  the  severe  infectious  fevers  affecting  the  ali- 
mentary canal,  such  as  cholera  or  yellow  fever.  In  cases  in  which 
the  symptoms  develop  slowly,  after  an  interval  of  a  day  or  more 
the  nervous  symptoms  predominate  over  those  of  the  gastroenteric 
system.  There  are  painful  muscular  cramps,  dyspnoea,  aphonia,  de- 
lirium, and  palpitation.  This  variety  of  poisoning  is  extremely  dan- 
gerous. 

There  is  another  group  of  cases,  less  often  seen,  in  which  the 
symptoms  are  of  gradual  onset,  longer  duration  and  closely  resemble 
those  of  paratyphoid  fever,  including  an  agglutination  reaction,  which 
may  be  obtained  from  the  blood.  In  acute  botulismus  there  may 
be  paralysis  of  the  ocular  and  pharyngeal  muscles  and  other  nerve 
symptoms. 

Diagnosis. —  The  diagnosis  is  almost  always  obtainable  from  the 
history  of  the  case  in  connection  with  the  symptoms  above  described, 
and  when  canned  food  has  been  eaten,  the  only  difficulty  consists  in 
determining  whether  the  poisoning  is  the  result  of  eating  tainted 
meat  or  of  acute  metallic  poisoning  from  chloride  of  zinc,  tin,  or 
lead  used  in  the  process  of  tinning  and  soldering  the  cans  (see  p.  430). 

Game  sometimes  disagrees  on  account  of  the  nature  of  the  food 
upon  which  the  animal  has  previously  been  living.  This  is  said  to 


FOOD   CONTAINING  PTOMAINES  423 

be  particularly  true  of  the  grouse  in  various  parts  of  the  country  at 
some  seasons  of  the  year.  The  laurel  buds  act  in  this  manner. 
Hares  fed  upon  rhododendron  are  poisonous  (Letheby). 

A  curious  instance  of  poisoning  from  eating  turkey  meat  was  re- 
ported by  Seelye,  of  Amherst,  Mass.  Several  young  women  at  a 
boarding  school  showed  symptoms  of  atropine  poisoning  after  eating 
a  bird  which  had  fed  upon  the  deadly  nightshade  berries. 

POISONING  BY  MILK,  CREAM,  ICE  CREAM,  AND  CHEESE 

Poisoning  by  milk  is  less  common  than  from  certain  varieties  of 
cheese  and  from  cream.  When  ice  cream  is  made  in  large  quan- 
tities, the  cream  is  allowed  to  accumulate,  and  if  a  portion  of  it  be- 
comes infected  with  pathogenic  organisms  it  will  soon  convert  the 
whole  mass  into  highly  poisonous  material.  In  a  small  town  in 
Indiana,  in  1900,  over  one  hundred  persons  were  seriously  poisoned 
by  ice  cream  from  soiled  cans.  Many  other  such  casualties  have  been 
observed  of  late  years.  Sixty-seven  men,  at  the  San  Juan  garrison 
in  Porto  Eico,  were  poisoned  in  1900  by  condensed  milk.  In  the 
U.  S.  Surgeon-General's  report  for  1900,  the  symptoms  are  described 
as  follows  by  Assistant  Surgeon  George  M.  "Wells,  U.  S.  A.: 

"  The  symptoms  were  persistent  vomiting,  severe  cramps  in  the 
stomach,  purging,  great  prostration,  dilatation  of  the  pupils,  head- 
ache, clammy  perspiration,  chilliness,  and  great  thirst.  The  stomach 
in  each  case  was  washed  out  by  means  of  the  stomach  tube.  In 
some  cases  the  stomach  was  empty,  and  nothing  but  water  and 
mucus  came  away;  in  others  the  washings  were  tinged  with  bile, 
and  in  others  again  a  moderate  amount  of  food  that  had  been 
eaten  for  breakfast  was  washed  out,  but  in  no  case  was  the  stomach 
overdistended  or  even  full.  The  prostration  was  so  great  that  some 
of  the  patients  fainted  before  reaching  the  ward.  A  large  number 
vomited  blood  in  small  clots,  in  most  instances  mixed  with  nothing 
but  mucus,  showing  that  the  hemorrhage  had  not  taken  place  until 
after  the  contents  of  the  stomach  had  been  expelled.  Purging  began 
in  most  before  the  vomiting  had  ceased,  and  continued  for  twelve  to 
fifteen  hours.  At  first  the  stools  were  natural,  soon  watery,  after- 
wards becoming  mucous  and  blood  tinged.  Cramps  in  the  voluntary 
muscles  were  mild  in  some,  but  other  patients  writhed  in  agony, 
their  sufferings  being  relieved  only  after  thorough  kneading  and 
massage  by  the  hospital  attendants.  Forty  were  discharged  from 
hospital  on  the  following  morning:  the  others  from  day  to  day  until 
the  fifth  morning,  when  all  were  returned  to  duty." 

Vaughan  and  Novy  have  thoroughly  studied  the  whole  subject  of 


424  DISEASES  CAUSED  BY  DIETETIC   ERRORS 

ptomaine  poisoning,  and  Vaughan  isolated  from  cheese  and  ice  cream 
a  toxin  to  which  he  has  given  the  name  of  "  tyrotoxicon,"  and  in 
Michigan  in  1883-'84  nearly  three  hundred  instances  of  cheese  poison- 
ing were  collected  by  him.  The  symptoms  of  tyrotoxicon  poisoning 
are  substantially  the  same  with  those  of  meat  poisoning,  consisting 
of  severe  gastrointestinal  disturbance  with  collapse. 

This  toxin  produces  almost  immediately  after  ingestion  by  a 
previously  healthy  infant,  violent  symptoms  of  cholera  morbus, 
which  prove  fatal  in  a  few  hours  unless  the  poison  can  be  eliminated. 
(See  Cholera  Morbus  Treatment,  p.  620.)  Of  this  poison  Vaughan 
says :  "  Post-mortem  examination  shows  but  little  change.  [There 
is  time  for  but  little  in  fatal  cases.]  The  mucous  membrane  of  the 
small  intestine  is  bleached  and  softened,  and  possibly  deprived  here 
and  there  of  its  superficial  epithelium." 

The  poison  apparently  acts  somewhat  as  the  toxin  of  Asiatic  chol- 
era, by  absorption  from  the  intestine,  and  by  violently  deranging  the 
nervous  and  vascular  systems,  producing  sudden  and  extreme  loss 
of  fluid  from  the  body  through  osmosis  into  the  intestine. 

C.  A.  Herter  has  recorded  the  case  of  a  man  who  died  five  days 
after  cheese  poisoning,  with  vomiting  prostration  and  cardiac  de- 
pression. The  proteus  vulgaris  bacillus  was  obtained  from  the 
vomitus. 

POISONING  BY  CRUSTACEANS,  SHELLFISH  AND  FISH 

Poisoning  by  shellfish  and  fish  results  from  infection  with  pto- 
maines developed  by  microorganisms,  as  in  cases  of  milk  and  meat 
poisoning.  In  addition,  it  should  be  remembered  that  there  are  a 
number  of  persons  who,  from  idiosyncrasy,  possess  extreme  sensi- 
tiveness to  the  action  of  shellfish  of  all  kinds.  To  such  persons 
the  eating  of  clam  broth  or  raw  oysters,  crabs  or  lobsters,  may  give 
rise  to  violent  outbreaks  of  urticaria  or  eczema,  or  produce  severe 
headache,  nausea,  and  vomiting.  It  is  scarcely  probable  that  these 
cases  are  due  to  the  same  source  as  those  of  true  ptomaine  poisoning, 
for  they  occur  when  the  shellfish  have  been  eaten  in  perfectly  fresh 
condition;  the  symptoms,  moreover,  are  usually  less  violent  than 
those  caused  by  ptomaines,  and  similar  effects  are  produced  in  some 
persons  by  certain  vegetables  and  fruits,  like  the  strawberry.  Among 
shellfish  the  mussel  furnishes  the  most  violent  poison.  This  substance 
Briefer  has  isolated  under  the  name  of  "  mytilotoxin."  It  develops 
particularly  in  the  liver  of  the  animal.  The  intensity  of  the  poison 
depends  somewhat  upon  the  locality  in  which  the  animal  has  lived  and 
fed.  The  same  mussels  mav  become  nontoxic  in  different  waters. 


GRAIN   POISONING  425 

Mytilism  also  occurs  from  eating  clams.  The  name  ichthysmus  is 
applied  to  fish  poisoning  in  general,  osteotoxismus  to  oyster  poison- 
ing. Three  deaths  occurred  in  Dover,  Michigan,  in  1907,  from  eat- 
ing tainted  oysters  at  a  banquet.  The  salted  sturgeon  which  is  eaten 
extensively  as  a  food  in  parts  of  Eussia  has  caused  death  from  its 
decomposition,  and  a  variety  of  fishes  both  in  European  and  Eastern 
waters  are  capable  of  developing  very  active  toxins.  In  Kussia  poison- 
ing has  been  produced  by  eating  the  ova  of  the  pike,  barbel,  and 
perch,  and  decomposed  sturgeon  roe  (caviare).  Portions  of  the 
porpoise,  eaten  in  China,  may  prove  poisonous  unless  thoroughly 
boiled.  The  mackerel  family  has  three  species  which  are  poisonous, 
namely  the  jurel,  bonito,  and  chicaro.  They  are  found  in  the  West 
Indies.  Two  species  of  herring  are  poisonous;  one  of  them,  the 
meletta,  taken  along  the  Atlantic  coast  from  Florida  to  New  York, 
has  caused  several  fatal  cases  of  poisoning. 

The  frequency  of  poisoning  by  eating  canned  lobster,  crabs,  or 
shellfish  is  due  mainly  to  the  rapidity  with  which  they  decompose 
and  develop  ptomaines  after  the  can  has  been  opened.  The  contents 
of  such  a  can  partially  used  should  not  be  kept  until  the  next  day. 

Symptoms. —  The  symptoms  of  poisoning  from  eating  fish  or 
mussels  in  which  ptomaines  have  developed  are  usually  different  from 
those  of  meat  and  milk  poisoning  in  that  they  concern  the  nervous 
system  with  less  gastrointestinal  disorder.  For  this  reason  the  poison 
is  much  more  dangerous,  and  cases  have  been  known  to  result  fatally 
two  hours  after  eating  mussels.  In  such  instances  there  may  be  no 
nausea,  vomiting,  or  fever,  but  there  is  sudden  and  extreme  prostra- 
tion, with  numbness,  faintness,  coldness  of  the  surface,  dilatation 
of  the  pupils,  double  vision,  restlessness,  nervousness,  anxiety,  and  a 
feeble  and  very  rapid  pulse.  In  France  hard-roed  herrings  have 
caused  such  symptoms.  Decomposing  oysters  and  fish  also  may  pro- 
duce symptoms  of  gastrointestinal  poisoning  resembling  those  from 
the  use  of  tainted  meat. 

Georgii  reported  in  1901  the  poisoning  of  24  men  from  eating  a 
salad  of  canned  lobster.  The  symptoms  resembled  fish  poisoning. 
Urticaria  was  absent,  but  in  one  case  there  was  glycosuria. 

VI.  Other  Food  Poisons  —  Grain  Poisoning,  etc. 

Flesh  may  become  poisonous  from  the  animal  having  fed  upon 

some  noxious  substance  shortly  before  it  was  killed.     The  flesh  of 

pigs  fed  on  garbage  may  cause  diarrhoea   (Parkes).     The  flavor  and 

digestibility  of  game,  and  fish,  varies  much  with  the  season  of  the 

30 


426  DISEASES  CAUSED  BY  DIETETIC   ERRORS 

year  and  the  consequent  nature  of  the  food  which  the  animal  has  had. 
Oysters  are  not  wholesome  food  from  May  to  September,  or  in  "  the 
months  without  an  '  R.' ):  Cow's  milk  becomes  unhealthful  for  in- 
fants when  the  animal  eats  improper  food  (see  p.  72),  and  rare  in- 
stances have  been  reported  of  illness  of  adults  caused  by  eating  meat 
poisoned  during  the  animal's  life,  as  in  the  case  of  a  sick  ox  to  which 
a  large  dose  of  tartar  emetic  was  given.  The  animal  died,  and  the 
meat  contained  enough  of  the  substance  to  poison  severely  those 
who  ate  it. 

Nutmeg  poisoning  is  described  on  page  292,  and  poisoning  by 
honey  on  page  159. 

GRAIN  POISONING 

Old  unripe  grain  and  moldy  flour  develop  poisons  from  decom- 
position of  their  gluten. 

Ergotism. —  The  fungus  known  as  ergot,  or  Claviceps  purpurea, 
grows  upon  rye,  and  in  Europe  the  careless  admixture  of  this  sub- 
stance with  grain  in  the  preparation  of  flour  has  several  times  re- 
sulted in  violent  symptoms  of  poisoning.  Collectively  the  symptoms 
are  described  as  "  ergotism,"  and  they  are  commonly  divided  into 
two  varieties,  the  gangrenous  and  the  convulsive.  The  ergot-con- 
taining flour  or  meal  must  have  been  eaten  for  a  considerable  time, 
as  a  rule,  in  order  to  develop  the  symptoms. 

In  the  gangrenous  form  of  ergotism  the  early  symptoms  are  refer- 
able to  local  vasomotor  disturbances,  affecting  principally  the  ex- 
tremities. These  symptoms  are  anaesthesia,  numbness,  prickling 
pain,  and  spasmodic  twitching  of  the  muscles,  with  an  impeded  blood 
flow  due  to  vasoconstriction.  In  the  convulsive  variety  the  nervous 
system  is  profoundly  disturbed.  After  a  period  of  indefinite  symp- 
toms, such  as  lassitude,  headache,  and  prickling  sensations,  spasms 
of  the  muscles  with  contractures  begin.  The  spasms  may  be  inter- 
mittent, or  may  assume  a  tetanic  character,  lasting  sometimes  through 
many  days;  the  arms  are  strongly  flexed  and  the  legs  and  toes  ex- 
tended. Spasmodic  rigidity  of  the  muscles  may  give  place  to  violent 
convulsions,  which  become  general  and  fatal.  There  is  sometimes 
slight  fever,  and  in  the  chronic  cases  melancholia  or  dementia  results. 
Delirium  also  is  present  sometimes.  In  cases  reported  by  Siemens 
and  Tuzzek  the  posterior  columns  of  the  spinal  cord  were  found 
sclerosed. 

Lathyrism. —  A  grain  called  the  chick-pea  vetch  is  sometimes  used 
for  adulteration  of  flour  from  various  cereals.  Several  varieties  are 
used  which  have  a  similar  effoct  to  ergot  in  producing  a  condition  of 


FOOD  ADULTEKATION  427 

spastic  rigidity  in  the  lower  extremities.  This  form  of  poisoning 
has  been  observed  in  India  by  James  Irving,  and  by  others  in  Italy 
and  France.  It  is,  however,  rare,  and  little  is  known  as  to  the  exact 
nature  of  the  lesions. 

Pellagra. —  Pellagra  is  a  disease  caused  by  eating  fermented  un- 
ripe maize  or  Indian  corn,  made  into  polenta.  It  is  unknown  in 
this  country,  but  prevails  in  the  south  of  Europe,  in  portions  of  Spain, 
France,  and  Italy.  The  first  symptoms  noticed  are  those  of  dyspepsia 
with  more  or  less  nervousness,  insomnia,  and  debility.  These  symp- 
toms are  followed  by  an  eruption,  the  pellagral  erythema,  which  de- 
velops in  the  spring.  After  the  eruption  has  lasted  for  some  time, 
the  skin  becomes  dry  and  extensive  desquamation  ensues  accompanied 
by  burning  pains,  or,  if  neglected,  the  surface  may  become  infected 
with  areas  of  suppuration.  With  the  appearance  of  the  eruption  the 
dyspeptic  symptoms  are  increased,  and  there  may  be  salivation  and 
severe  diarrhoea.  The  disease  lasts  in  greater  or  less  severity  for 
several  months  and  ends  in  slow  convalescence,  or  else,  in  the  worst 
forms,  the  nervous  system  is  involved  and  emaciation,  headache,  con- 
vulsions, delirium,  and  paralysis  of  the  legs  may  appear.  The  peas- 
ants who  eat  this  spoiled  food  sometimes  have  severe  attacks  in 
successive  years,  and  melancholia  and  suicidal  mania  have  been 
observed  among  them.  There  are  no  definite  lesions  other  than 
those  of  malnutrition,  such  as  fatty  degeneration  of  various  organs 
(Arnold). 

The  disease  is  said  to  be  preventable  by  adding  salt  to  the  corn- 
meal;  but  salt  is  a  Government  monopoly  in  Italy.  The  peasants 
resist  the  tax  upon  it,  and,  through  prejudice  as  much  as  through 
ignorance  and  poverty,  may  fail  to  make  use  of  it. 

VII.  Food  Adulteration 

Food  adulteration  consists  of :  1.  The  addition  of  deleterious  sub- 
stances. 2.  Fraudulent  substitution  of  cheaper  articles  of  food  or 
the  sale  of  food  not  as  fresh  or  good  as  it  is  represented. 

A.  J.  Wedderburn,  in  a  report  to  the  United  States  Department 
of  Agriculture,  makes  the  statement  that  of  all  food  products  sold 
in  this  country,  15  per  cent  is  adulterated,  but  only  2  per  cent  is 
deleterious. 

The  extent  to  which  food  adulteration  prevailed  in  this  country 
prior  to  the  passage  in  1906  of  the  Pure  Foods  Act  is  illustrated 
in  the  following  table  of  examinations  made  in  a  single  State  (Ken- 
tucky) by  the  Agricultural  Experiment  Station.  Forty  per  cent  of 
all  samples  taken  were  found  adulterated. 


428 


DISEASES   CAUSED  BY   DIETETIC   ERRORS 


Kind  and  Number  of  Samples   Collected  from  June  13,  1898,   to  December 

31,  1899. 


ARTICLES  SAMPLED. 

Not  found 
adulterated. 

Adulterated. 

Total. 

Baking  powder    

11 

45 

56 

Butter    

118 

29 

147 

Canned  goods  

6 

6 

Catsups,  pickles,  etc  

12 

45 

57 

Coffee     

2 

1 

3 

Cornstarch    

1 

1 

Flour    (wheat)     

20 

20 

Jellies,  preserves,  etc  

5 

18 

23 

Lard       .          

29 

11 

40 

Milk  (sweet  and  buttermilk)    

115 

35 

150 

Milk  color  

1 

1 

Mince-meat  

7 

7 

Oleomargarine     

2 

16 

18 

Olive  oil  

1 

1 

2 

3 

11 

14 

Sweet  cider  and  grape  juice  

3 

3 

Soda  (  cooking  soda  )      

3 

3 

Sirups,  honey,  and  sugar   

41 

9 

50 

Vinegar       

67 

59 

126 

Total    

437 

290 

727 

At  the  Connecticut  Agricultural  Experiment  Station,  41^  per 
cent  of  574  samples  of  spices  were  found  adulterated,  and  over  25 
per  cent  of  coffee  samples  were  adulterated  (1899). 

The  object  of  adulteration  of  food  —  namely,  to  cheapen  cost  of 
production  —  is  attained  by  (a)  increasing  the  bulk,  (&)  altering 
the  appearance,  and  (c)  giving  false  strength. 

In  many  States  as  well  as  by  the  Congress,  stringent  laws  have  been 
enacted  against  all  adulteration  of  food  products,  beverages,  and  drugs, 
but  the  ingenuity  of  manufacturers  and  dealers  in  evading  them  neces- 
sitates the  constant  vigilance  of  the  experts  of  health  boards. 

Among  the  common  adulterations  may  be  mentioned  the  follow- 
ing: Isinglass  adulterated  with  gelatin;  wheat  flour  with  bran  or 
cowpeas ;  powdered  sugar  with  barium  sulphate ;  mustard  with  flour 
and  turmeric  or  cornmeal  to  the  extent  of  90  per  cent;  "essences" 
of  peppermint,  cinnamon,  etc.,  with  poisonous  wood  alcohol;  distilled 
colored  vinegar  sold  as  cider  vinegar;  pickles  adulterated  with  iron 
and  copper;  oleomargarine  sold  as  butter;  ground  spices  are  adul- 
terated with  cocoanut  shells,  rice,  flour  and  ashes;  water,  sugar  and 
tartaric  acid  are  sold  as  lemonade.  Wines  and  liquors  are  sometimes 
adulterated  with  alum,  baryta,  caustic  lime,  salts  of  lead,  salicylic 
acid  and  haematoxylon. 

Candies  arc  adulterated  with  terra  alba,  kaolin,  and  various  pig- 


FOOD   ADULTERATION  429 

ments,  and  the  different  chewing  gums,  gum  drops,  etc.,  are  largely 
made  with  petroleum-paraffin  products. 

Most  of  the  maple  sugar  sold  is  made  from  glucose,  and  "maple 
sugar  "  is  also  derived  from  other  sugars  and  artificially  flavored  with 
extract  of  hickory  bark  (Wiley) . 

Cotton-seed  oil  is  often  sold  as  olive  oil. 

Nearly  half  the  liquid  honey  sold  is  adulterated  with  glucose. 

Cocoa  and  chocolate  are  adulterated  frequently  but  harmlessly  with 
both  starch  and  sugar. 

Coffee  is  extensively  adulterated  with  sugar,  caramel,  pea  meal, 
chicory,  and  saccharin  extracts.  Coffee  berries  are  artificially  made 
in  molds  out  of  mixtures  of  starch,  molasses,  or  caramel,  chicory, 
etc. 

Baking  powder  is  often  adulterated. 

Vaseline  is  sometimes  used  to  adulterate  butter  for  making  pastry 
and  cakes.  It  does  not  become  rancid,  and  is  therefore  difficult  of 
detection.  Fortunately,  it  is  not  especially  harmful. 

Pigments. —  Artificial  coloring  matters  are  added  to  foods,  both  to 
deceive  intentionally  and  also  merely  to  make  different  substances, 
such  as  preserved  green  vegetables,  candies,  or  confections,  appear 
more  attractive  to  the  eye. 

Formerly  highly  injurious  copper  or  zinc  salts  were  much  used 
to  color  canned  peas  and  beans,  and  not  infrequently  they  were  found 
in  poisonous  quantities,  but  the  green  plant  pigment  chlorophyll 
is  so  much  cheaper,  and  is  so  abundant  and  harmless,  that  it  has 
superseded  them  almost  entirely  since  its  introduction  for  this  pur- 
pose in  1877. 

Ultramarine  is  much  used  to  color  sirups;  safranin,  eosin,  fuch- 
sine,  anilin  violet,  and  many  other  anilins  are  employed  in  the  manu- 
facture of  candies,  as  is  also  cochineal.  So  little  of  these  substances 
is  required,  however,  as  seldom  to  prove  injurious. 

The  pigments  most  in  vogue  to  color  butter  and  cream  are  tur- 
meric, saffron,  an  orange  pigment  from  the  stigmas  of  a  flower,  sul- 
phonated  anilin  yellow,  and  annotto,  a  yellow  pigment  derived  from 
the  fruit  of  a  South  American  tree.  Annotto  as  used  by  dairymen 
to  color  milk  and  cream  is  not  harmful.  To  detect  it,  add  a  tea- 
spoonful  of  baking  soda  to  a  quart  of  the  milk,  and  immerse  in  it 
a  strip  of  unglazed  paper.  In  a  few  hours  the  latter  becomes  orange- 
colored  if  annotto  is  present  (Leffmann). 

Certain  substances  like  borax  and  salicylic  acid  are  added  to  foods 
as  preservatives,  rather  than  adulterants,  although  strictly  speaking 
they  may  be  classed  as  adulterants.  They  are  described  on  page  314. 


430  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

NATIONAL,  BUKEAU  OF  MEDICINES  AND  FOODS 

Efforts  to  establish  a  National  Bureau  of  Medicines  and  Foods, 
designed  especially  to  prevent  adulteration  and  misrepresentation, 
are  being  made  by  the  American  Medical  and  the  American  Pharma- 
ceutical Associations,  and  it  is  to  be  hoped  that  Congressional  sanction 
of  the  plan  soon  may  be  obtained.  If  such  a  Bureau  were  established 
as  a  part  of  a  broader  Department  of  Public  Hygiene,  with  repre- 
sentation in  the  Cabinet,  it  would  contribute  towards  advancing  this 
country  in  matters  sanitary  and  hygienic  to  the  standards  of  some 
of  the  continental  countries  which,  in  these  respects,  are  at  present 
far  in  the  lead. 

The  importation  of  adulterated  foods  from  foreign  countries  is 
well  guarded  against  by  existing  customs  regulations,  but  the  various 
State  laws  against  such  adulteration  are  in  great  need  of  uniform 
codification.  It  is  to  be  expected  that  the  National  Pure  Foods  Act 
will  in  future  prohibit  such  adulterations  as  those  herein  described. 

COPPER,   TIN,  LEAD  AND  ZINC  POISONING 

These  forms  of  poisoning  may  arise  from  the  prolonged  use  of 
canned  meats,  vegetables,  or  fruits.  In  tin  cans  lead  is  derived  from 
the  action  of  various  organic  acids  upon  the  solder  (which  in  this 
country  is  usually  50  per  cent  lead),  and  the  tin  used  for  coating 
the  inside  of  the  can  eventually  is  dissolved  in  a  similar  manner. 
(See  also  Canning,  p.  312.) 

Wiley  says :  "  The  tin  of  some  cans  has  been  found  to  contain 
as  high  as  12  per  cent  of  lead.  ...  In  addition  to  this  there 
is  no  care  taken  to  prevent  the  solder  from  coming  in  contact  with 
the  contents  of  the  can.  It  is  a  rare  thing  to  carefully  examine  the 
contents  of  a  can  without  finding  pellets  of  solder  somewhere  therein. 

"  Another  great  source  of  danger  from  lead  has  been  disclosed  by 
the  analytical  work,  viz.,  in  the  use  of  glass  vessels  closed  with  lead 
tops  or  with  rubber  pads,  in  which  sulphate  of  lead  is  found  to  exist." 

In  De  Long's  Arctic  Expedition  several  men  suffered  severely  from 
lead  poisoning  from  the  solder  used  in  canning  tomatoes,  traces  of 
lead  being  found  on  examining  the  contents  of  the  can.  The  acid 
of  the  tomato  acts  upon  the  solder,  forming  a  soluble  lead  salt.  The 
cans,  however,  had  been  kept  for  a  period  of  two  years  before  their 
contents  were  eaten. 

Johnson  (in  The  Medico-Legal  Journal,  vol.  iii,  p.  53)  reports 
cases  of  dangerous  poisoning  from  eating  tinned  tomatoes  which  were 
accompanied  by  symptoms  of  violent  gastritis,  stupor,  and  coma. 


FOOD  ADULTERATION  431 

The  amount  of  tin  dissolved  is  directly  proportionate  to  the  age  of 
the  contents  of  the  cans.  The  food  in  cans  that  have  been  unopened 
for  two  or  three  years  is  very  apt  to  produce  poisonous  effects. 
Professor  Bettink  declares  that  malic  acid  is  the  solvent  of  the  tin 
when  fruits  and  vegetables  are  canned. 

Hehner  examined  many  canned  foods,  and  found  tin  present,  in 
most  of  them  as  a  stannous  hydrate,  which  existed  in  sufficient  quan- 
tity to  be  fatal  when  given  to  guinea  pigs. 

Ungar  and  Bodlander  have  reported  a  number  of  cases  of  poison 
from  canned  asparagus.  Tin  present  in  such  food  in  an  insoluble 
form  may  be  dissolved  and  absorbed  during  digestion. 

Professor  Beckurts  reported  that  a  sulphate  of  tin  is  formed  by 
the  action  of  vegetable  albuminoids  or  of  meat  albumin  on  the  can. 
This  is  very  liable  to  take  place  with  canned  asparagus,  and  two 
cases  of  severe  poisoning  of  this  nature  have  come  under  my  per- 
sonal observation.  Violent  gastrointestinal  symptoms  occurred, 
such  as  severe  vomiting  and  diarrhoea,  accompanied  by  faintness 
and  vertigo.  The  symptoms  appeared  within  two  or  three  hours  after 
eating  the  asparagus  from  cans  which  had  been  kept  for  a  long 
time. 

Winckel  reported  the  cases  of  270  soldiers  who  had  been  made  ill 
from  eating  lettuce  and  meat  preserved  in  tins.  In  their  cases  it  was 
estimated  that  the  quantity  of  tin  in  solution  was  from  19  to  72  milli- 
grams per  kilogram.  Eoos  advises  the  coating  of  such  cans  on  the 
inside  with  insoluble  varnish,  which  prevents  the  albuminoids  or 
vegetable  acids  from  coming  in  contact  with  the  tinned  surface  and 
dissolving  the  metal.  He  found  upon  opening  a  can  of  asparagus 
preserved  for  thirty-one  years  that  the  inside  tin  coating  was  com- 
pletely dissolved  in  the  liquid.  A  can  of  beef  preserved  for  eight 
years,  weighing  976  grams,  contained  77  milligrams  of  oxide  of  tin, 
and  a  can  of  asparagus  preserved  only  four  months  contained  11  milli- 
grams of  oxide  of  tin  and  6  of  copper.  Preserved  apples,  corn, 
apricots,  meats,  and  soups  have  also  all  been  found  to  possess  the  same 
solvent  action  upon  tin  cans.  This  is  almost  entirely  prevented  in 
those  instances  in  which  a  coating  of  varnish  has  been  put  over  the 
tinned  surface.  Pears  cooked  in  a  tin  stewpan  have  been  known  to 
cause  severe  poisoning.  One  hundred  and  fifty  cases  of  serious  metal- 
lic poisoning  occurred  among  the  soldiers  of  a  Tyrolese  regiment  who 
ate  food  from  a  tin-lined  copper  kettle. 

In  general,  food  cooked  or  allowed  to  stand  for  any  length  of 
time  in  either  brass  or  copper  vessels  not  kept  absolutely  clean  is 
dangerous  to  life. 


432  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

VIII.  Food  Containing  Microorganisms  of  Infectious  Diseases 

MILK    INFECTIONS 

Milk  is  an  admirable  culture  medium  for  a .  great  variety  of 
germs,  and  some  bacilli,  like  those  of  typhoid  fever  and  tuberculosis, 
thrive  particularly  well  in  it.  Moreover,  its  abundant  and  varied 
proteid  furnishes  substance  out  of  which  to  develop  powerful  toxins 
for  absorption. 

The  following  are  the  chief  diseases  whose  germs  are  capable  of 
being  conveyed  by  milk:  Tuberculosis,  typhoid  fever,  cholera,  diph- 
theria, scarlet  fever. 

Milk,  and  food  in  general,  should  never  be  kept  standing  in  an  ice 
box  or  cellar  near  an  open  or  defective  drain,  as  it  becomes  rapidly 
tainted  in  noxious  air. 


Tubercular  Milk  Infection. —  This  matter  is  of  special  importance 
in  regard  to  the  danger  of  conveying  tuberculosis  to  infants  through 
raw  milk.  The  transmission  of  tuberculosis  to  man  from  cow's  milk 
was  first  definitely  described  by  Klencke  in  1846,  who  demonstrated 
tuberculous  conditions  in  16  children,  and  in  the  cows  from  which 
the  children  had  been  given  milk.  The  identity  of  bovine  and  hu- 
man tuberculosis  was  universally  accepted  until  1896,  when  Theobald 
Smith  pointed  out  certain  biologic  and  morphologic  differences,  and 
Koch  in  1901  asserted  that  bovine  tuberculosis  is  nontransmissible 
to  man,  thereby  retracting  his  former  views  stated  in  1882.  Koch 
declared  in  1901  that  bovine  tuberculosis  bacilli  are  more  fatal  to 
cattle  and  other  domestic  quadrupeds  than  are  the  human  tubercu- 
losis bacilli  to  these  animals,  and  that  primary  intestinal  tubercu- 
losis is  so  rare  in  man  as  to  preclude  the  possibility  of  milk  infection. 
This  unexpected  statement  gave  a  great  stimulus  to  further  research 
and  a  large  number  of  competent  bacteriologists  have  since  demon- 
strated beyond  question  that  human  tuberculosis  may  be  inoculated 
in  cattle,  and  both  human  and  bovine  tuberculosis  may  be  inoculated 
in  monkeys.  George  M.  Kober  in  1903  tabulated  86  cases  of  hu- 
man tuberculosis  derived  from  cow's  milk,  and  a  number  of  others 
have  been  reported  by  different  clinicians.  Thus,  although  the  dan- 
ger of  milk  infection  from  cows  to  man  is  slight,  it  is  distinctly 
established  (notwithstanding  Koch's  views),  and  the  morphological 
differences  in  ihe  two  varieties  may  be  offset  by  degrees  of  virulence 
which  make  the  interchange  of  the  disease  possible  from  cattle  to 
man  and  vice  versa. 


FOOD   CONTAINING   MICROORGANISMS  433 

D.  E.  Salmon  in  the  U.  S.  Bureau  of  Animal  Industry,  No.  38, 
1905,  presents  the  following  conclusions  based  upon  extensive  re- 
search in  that  Department. 

"  1.  Bovine  tuberculosis  may  be  communicated  to  human  beings, 
and  in  such  cases  it  is  usually  children  that  are  affected. 

"  2.  Tuberculosis  of  other  domesticated  mammals  (hogs,  sheep, 
goats,  etc.)  also  may  be  communicated  to  human  beings.  It  is 
usually,  but  not  always,  of  the  bovine  type. 

"  3.  The  tuberculosis  of  poultry  is  not  communicable  to  human 
beings. 

"  4.  The  tuberculosis  of  human  beings,  as  a  rule,  is  not  com- 
municable to  cattle,  but  is  communicable  to  pigs,  dogs,  and  cats. 
The  bacilli  in  a  certain  proportion  of  the  cases  of  human  tubercu- 
losis, however,  are  virulent  for  cattle  and  produce  in  these  animals 
a  fatal  generalized  tuberculosis. 

"  5.  Precautions  should  be  taken  to  protect  human  beings  from 
animal  tuberculosis  by  a  careful  inspection  of  meat-producing  animals 
at  the  time  of  slaughter  and  of  the  cows  from  which  milk,  cream, 
and  butter  are  produced." 

Bovine  tuberculosis  has  also  been  communicated  to  man  by  ac- 
cidental inoculation  of  wounds,  fresh  tattoo  marks,  skin  eruptions, 
etc.,  to  which  tuberculous  milk  had  been  applied  for  its  supposed 
healing  action.  Butchers  and  veterinarians  have  been  inoculated 
through  accidental  wounds  while  handling  the  carcasses  of  tubercu- 
lous cattle.  State  boards  of  health  in  this  country  are  everywhere 
endeavoring  to  secure  proper  legislative  authority  to  inspect  and 
condemn  tuberculous  cattle. 

Milk  infected  with  tubercle  bacilli  when  fed  to  animals  has  been 
shown  to  produce  primary  intestinal  and  mesenteric  tuberculosis, 
and  this  may  occur  in  infants.  H.  C.  Ernst  produced  tuberculosis 
in  pigs  by  feeding  them  milk  from  tuberculous  cows  when  the  latter 
had  normal  udders.  Cow's  milk  may  contain  tubercle  bacilli  when 
the  disease  is  located  in  the  lungs  of  the  animal  (Ernst).  It  is 
possible  that  this  is  the  case  with  the  milk  of  tuberculous  mothers, 
although  it  is  not  yet  an  established  fact.  The  danger  to  the  infant 
is  less  in  such  cases,  for  the  disease  in  the  mother  is  usually  recog- 
nized in  time  to  discontinue  breast  nursing. 

It  is  difficult  to  arrive  at  any  accurate  estimate  of  the  total  num- 
ber of  tuberculous  cows  in  the  United  States,  where  upwards  of 
5,000,000  milch  cows  are  maintained,  and  systems  of  dairy  inspec- 
tion are  of  comparatively  recent  date. 

It  has  been  estimated  in  regard  to  the  Eastern  States  that  15  per 


434  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

cent  of  the  common  dairy  stock  was  tuberculous,  prior  to  State  regula- 
tion of  this  matter.  Stall-fed  animals  who  live  in  filthy  barns  and 
have  little  exercise  show  the  largest  percentage  of  infection.  In 
healthy  adults  the  gastric  juice  may  succeed  in  destroying  tubercle 
bacilli  swallowed  with  such  food,  and  no  doubt  it  often  does  so. 
Fortunately  the  milk  of  all  tuberculous  cows  does  not  contain  the 
bacilli,  but  it  is  almost  certain  to  do  so  when  the  udders  become 
involved  in  the  disease.  In  large  dairies  the  cows  should  be  given 
the  tuberculin  test  once  in  six  months,  and  if  they  respond  should 
be  condemned  as  milk  producers.  (Conference  of  State  Boards  of 
Health.) 

The  tuberculosis  bacillus  has-been  kept  alive  in  butter  128  days, 
and  animals  have  been  given  tuberculosis  by  experimental  inocula- 
tion with  butter  made  from  the  milk  of  tuberculous  cows,  but  there 
are  no  authentic  instances  of  the  transmission  of  the  disease  to 
man  through  this  agency.  The  germ  has  also  been  found  in  cheese. 
Tubercular  Meat  Infection. —  Tubercular  meat  usually  proves  less 
virulent  than  raw  milk,  probably  because  it  is  subjected  to  thorough 
heat  in  cooking,  but  all  the  bacilli  are  not  invariably  killed  by  im- 
perfect cooking,  and  infected  meat  or  milk  should  on  no  account 
be  eaten.  This  fact  is  being  gradually  appreciated  by  the  public,  and 
meat  inspection  at  abattoirs  is  now  much  better  regulated  by  law  and 
supervised  by  local  health  boards  than  formerly;  but  Billings  says 
that  "  probably  one-half  of  one  per  cent  of  the  beef  sold  in  market 
comes  from  animals  in  whom  tubercle  existed  at  the  time  of 
death." 

All  slaughtering  should  be  done  in  public  abattoirs  under  com- 
petent inspection,  and  not  only  should  the  animals  be  examined  be- 
fore killing,  but  the  meat  should  be  inspected  afterwards. 

The  Bacillus  tuberculosis  has  been  found  not  only  in  the  meat  or 
muscle  of  the  animal  butchered,  but  in  the  liver,  kidneys,  and  other 
viscera.  The  bacillus  is  not  killed  by  salting  meat  nor  always  by  its 
digestion  in  the  stomach.  Moreover,  salt  meat  is  not  so  thoroughly 
cooked  as  fresh  meat,  as  a  rule. 

Theobald  Smith  states  that  it  is  doubtful  whether  the  muscles  of  cat- 
tle ever  contain  bacilli,  but  the  latter  are  liable  to  be  smeared  over  the 
meat  by  the  butcher's  knife  fresh  from  cutting  into  a  tubercular 
lymphatic  gland  or  lung. 

The  total  number  of  tuberculous  cattle  in  the  United  States  is 
not  known.  The  tuberculin  tests  reveal  many  herds  entirely  free 
from  it,  whereas  others  have  been  found  almost  universally  infected, 
there  being  much  variation  in  different  parts  of  the  country.  The 


FOOD  CONTAINING  MICROORGANISMS  435 

State  Veterinarian  of  Pennsylvania  estimates  that  2  per  cent  of 
cattle  in  that  State  are  tuberculous. 

D.  E.  Salmon,  chief  of  the  Bureau  of  Animal  Industry,  reported 
in  1899: 

"  The  beef-cattle  which  come  from  large  abattoirs  are  singularly 
free  from  tuberculosis,  only  1  animal  in  1,500  or  2,000  being  af- 
fected to  an  extent  to  cause  condemnation  of  any  part  of  the  carcass. 
Dairy  cattle  may  be  affected  to  the  extent  of  5  to  10  per  cent!  In 
Europe,  the  slaughter-house  statistics  show  from  20  to  50  per  cent 
of  all  cattle  slaughtered  to  be  affected  with  tuberculosis." 

"  Tuberculosis  is  one  of  the  principal  diseases  of  swine,  but  is 
found  only  in  1.3  carcasses  per  10,000  animals. 

Among  sheep  tuberculosis  is  very  rare.  The  Bureau  of  Animal 
Industry  in  1905  found  only  27  cases  among  7,872,671  animals 
slaughtered. 

Other  Infections. —  Meat  from  animals  dead  of  various  acute  dis- 
eases is  sometimes  eaten,  and  if  well  cooked  may  be  harmless,  but 
it  is  not  good  food,  and  no  part  of  any  animal  suffering  from  the 
foot-and-mouth  disease  (or  cattle  plague),  rabies,  glanders,  actino- 
mycosis,  anthrax,  septicaemia,  swine  plague,  sheep  or  cowpox,  pneu- 
monia, trichinosis,  or  tuberculosis  should  ever  be  eaten. 

TYPHOID  AND  CHOLKRA  INFECTION 

Typhoid  infection  is  undoubtedly  conveyed  through  milk  which 
has  been  diluted  with  water  contaminated  from  a  barnyard  well  or 
cesspool,  or  which  has  been  placed  in  cans  rinsed  in  such  water. 
Hankin  describes  cases  of  this  fever  derived  from  eating  dahi,  a 
curdled  milk  made  by  East  Indian  confectioners.  Fraenkel  found 
that  typhoid  bacilli  may  live  in  acid  buttermilk. 

Three  hundred  and  eighty-six  cases  from  milk  infection  occurred 
at  Stamford,  Conn.,  in  May,  1895.  Another  epidemic  occurred  in 
York,  Pa.,  in  1899,  and  two  extensive  epidemics  were  traced  to  this 
source  in  Philadelphia  in  1903,  the  milk  dealers  having  been  found 
to  have  cases  of  typhoid  fever  in  their  own  families. 

At  Coseley,  near  Birmingham,  England,  five  cases  of  typhoid  fever 
were  traced  to  infection  from  ice  cream. 

Infection  with  Typhoid-fever  Germs  Through  Eating  Oysters. — 
An  epidemic  of  typhoid  fever  occurred  at  Wesleyan  University  in 
the  latter  part  of  November,  189-i,  which  affected  only  certain  stu- 
dents to  the  number  of  thirty,  who  had  attended  a  college-society 
supper  and  eaten  raw  oysters.  A  very  thorough  investigation  was 
made  by  Prof.  H.  W.  Conn  into  the  etiology  of  the  epidemic,  and 


436  DISEASES  CAUSED  BY  DIETETIC  ERRORS 

the  following  account  of  it  was  published  in  the  New  York  Times  on 
November  20,  1894: 

"  The  oyster  grower,  who  lives  on  the  shore  of  the  Quinnipiac 
Eiver,  a  stream  which  flows  into  New  Haven  harbor,  had  been  in 
the  habit  of  laying  down  his  oysters  for  a  day  or  two  in  the  river, 
after  taking  them  from  the  deep  salt  waters  of  the  Sound  and  before 
putting  them  on  the  market.  At  about  the  time  when  the  first  cases 
appeared  at  the  university  his  wife  died  of  typhoid  fever.  His 
daughter  had  been  ill  with  the  same  disease.  The  oysters  which 
were  sold  to  the  students  had  been  bedded  temporarily  in  the  river 
at  a  point  near  the  place  where  a  short  drain  from  his  house  dis- 
charges into  the  stream.  The  water  became  infected  by  the  flow 
from  the  drain,  and  when  the  oysters  were  taken  up  the  liquid  and 
other  matter  which  accompanies  oysters  so  dislodged,  either  on  the 
outside  of  the  shell  or  inside  of  it,  contained  the  germs  of  typhoid." 

According  to  Foote,  of  New  Haven,  the  typhoid  bacillus  will  live 
eight  days  in  water  from  an  oyster  bed.  The  oyster  juice  also  con- 
tains the  bacilli,  and  the  bacilli  injected  into  oysters  live  a  fortnight 
in  abundance,  and  a  few  have  survived  for  thirty  days.  Two  fatal 
cases  of  typhoid  fever  have  been  reported  in  Berlin  as  due  to  infec- 
tion from  raw  oysters.  Sir  William  Broadbent  reported  in  the  Brit- 
ish Medical  Journal  ten  cases  which  he  saw  during  November  and 
December,  1894,  and  attributed  to  the  same  origin.  A  number  of 
cases  have  been  traced  in  Italy  and  France  to  the  eating  of  raw  oys- 
ters. Arthur  Newsholme,  of  Brighton,  England,  studied  181  cases 
of  typhoid  fever  occurring  there  from  1893  to  1896,  of  which  nearly 
one-third  were  attributed  to  eating  raw  shellfish  —  36  to  oysters,  and 
20  to  other  varieties.  All  the  shellfish  were  contaminated  by  sewage. 
In  1903  an  epidemic  of  typhoid  fever  in  London  was  traced  to  the 
eating  of  shellfish  contaminated  by  sewage,  and  in  the  same  year  18 
cases  occurring  in  Glasgow  were  traced  to  the  eating  of  cockles  sim- 
ilarly contaminated.  Typhoid  bacilli  were  obtained  from  the  cockles 
and  gave  the  agglutination  reaction.  Eight  other  cases  developed  in 
one  family  in  a  neighboring  town,  all  of  whom  had  eaten  the  cockles. 

Oysters  may  also  give  rise  to  severe  enteritis,  and  possibly  cholera 
when  derived  from  infected  sewage  beds.  Frankland,  however,  has 
determined  that  cholera  bacilli  injected  into  oysters  do  not  survive 
more  than  twenty-four  hours. 

It  is  possible,  although  not  definitely  proved,  that  typhoid  bacilli 
may  be  conveyed  upon  raw  vegetables  and  fruits  which  have  been 
washed  in  contaminated  water.  It  is  known  that  cholera  germs  are 
conveyed  in  this  way.  For  this  reason,  as  well  as  from  the  necessity 


FOOD   CONTAINING   MICROORGANISMS  437 

of  avoiding  diarrhoea,  it  is  customary  to  advise  against  the  use  of  all 
raw  fruits  and  vegetables  during  the  prevalence  of  a  cholera  epidemic. 

DIPHTHERIA  AND  SCARLATINA 

Diphtheria  germs,  and  those  of  scarlatina,  may  be  conveyed  in  milk 
should  they  have  access  to  it.  Several  epidemics  of  both  diseases  have 
been  traced  among  families  employing  in  common  a  milkman  whose 
children  at  home  had  one  or  the  other  disease.  In  Buffalo,  N.  Y.,  in 
1899,  an  epidemic  of  29  cases  of  scarlatina  was  definitely  traced  to 
consumption  of  milk  delivered  by  one  milkman,  who  obtained  the  sup- 
ply from  a  farmer  who  had  the  disease  at  the  time  of  milking. 

FOOT-AND-MOUTH   DISEASE 

The  foot-and-mouth  disease  may  be  propagated  from  the  use  of 
milk  from  an  infected  cow.  Sometimes  this  milk  is  of  a  bad  taste 
and  odor,  or  it  may  be  mixed  with  blood  or  pus  if  the  nipples 
are  excoriated  or  if  the  udders  are  inflamed.  In  other  cases  the  milk 
appears  normal,  but  when  boiled  coagulates  into  small  flocculi  in  a 
bluish  whey.  Such  milk  is  rendered  innocuous  by  the  process  of 
boiling.  Children  are  more  likely  to  contract  the  disease  in  this  way 
than  are  adults,  owing  to  their  greater  consumption  of  cow's  milk. 

The  gums  become  swollen,  red,  and  tender,  aphthous  ulcers  appear 
on  the  lips  and  gums,  the  submaxillary  glands  and  tonsils  may  be 
swollen,  vesicles  and  pustules  may  appear  on  the  tongue,  lips,  and 
extremities,  and  there  is  moderate  fever  with  vomiting  and  diarrhoea. 
The  disease  promptly  subsides  on  stopping  the  use  of  infected  milk. 

FOOD  INFECTION  THROUGH  FLIES 

The  importance  of  preventing  food  infection  through  the  agency 
of  common  house  flies  is  very  great.  These  insects  are  admirably 
adapted  to  convey  infection  owing  to  their  large  numbers  and  incessant 
activity,  as  well  as  their  numerous  feet,  capacious  intestines,  their 
frequent  evacuations,  and  disgusting  habits  of  alighting  and  feeding 
upon  sputum,  manure  heaps,  and  all  animal  discharges.  When  fed  on 
tubercular  sputum  the  bacilli  have  been  discovered  alive  in  their  intes- 
tines, retaining  their  virulence  for  15  days  (F.  T.  Lord),  and  cholera 
germs  have  been  found  adhering  to  their  feet  by  which  they  are  easily 
transported  from  a  choleraic  stool  to  a  piece  of  bread  or  a  raw  fruit 
or  vegetable,  destined  in  turn  to  infect  the  first  person  who  is  unlucky 
enough  to  eat  it.  During  the  cholera  epidemic  in  Hamburg  Dr.  Sim- 
monds  found  cholera  bacilli  in  the  intestines  of  flies  in  the  post- 
mortem room  where  dead  cholera  patients  were  examined.  The 


438  DISEASES   CAUSED  BY   DIETETIC  ERRORS 

bacilli  remained  one  and  a  half  hour  in  the  flies  —  time  enough  to  be 
carried  a  long  distance  or  to  be  widely  distributed.  Ordinary  pus 
infection  is  readily  carried  by  flies.  In  the  hastily  constructed  camps 
of  our  troops  in  the  Spanish-American  War,  and  in  those  of  the  Brit- 
ish soldiers  in  the  Boer  War,  many  cases  of  typhoid  fever  were  traced 
to  infection  by  flies  that  had  access  to  the  latrines  into  which  typhoid 
stools  had  been  emptied.  When  the  matter  is  further  investigated  it 
doubtless  will  be  shown  that  other  kinds  of  infection  are  often  spread 
by  the  medium  of  these  vulgar  pests. 

IX.  Idiosyncrasies  in  Regard  to  Food 

Idiosyncrasies  are  found  to  exist  with  some  persons  in  regard  to 
special  foods  which  cannot  readily  be  explained.  As  a  rule,  if 
marked,  they  extend  throughout  life,  but  it  is  not  seldom  the  case  that 
some  persons  pass  through  periods  when  a  particular  food  disagrees 
with  them  which  they  have  been  able  previously  to  eat  with  impunity. 
Some  are  unable  to  digest  milk  and  are  immediately  nauseated  or 
made  "bilious"  by  it.  There  are  several  authentic  cases  on  record 
of  persons  who  cannot  eat  eggs  in  any  form,  even  disguised  in  pud- 
dings, etc.,  without  distinct  toxic  symptoms,  such  as  severe  headache, 
nausea,  vomiting,  urticaria,  etc.  Some  persons  cannot  eat  fat  in  any 
form  or  are  unable  to  digest  some  one  variety  of  fat,  especially  hot 
mutton  fat.  Some  persons  acquire  a  headache  whenever  they  eat 
butcher's  meat  in  excess.  Among  the  commoner  idiosyncrasies  of  diet 
are  the  revolt  of  the  system  which  occurs  from  the  use  of  shellfish  of 
all  kinds,  but  especially  lobsters,  and  from  strawberries.  Fothergill 
reported  the  case  of  a  lady  who  all  her  life  was  unable  to  drink  coffee, 
of  which  she  was  very  fond,  without  having  diarrhoea  from  it  within 
an  hour  or  two.  Temporary  or  functional  visual  disturbances  may 
be  produced  by  alcohol  and  by  indulgence  in  "  high  "  game.  Casey 
A.  Wood,  of  Chicago,  has  reported  a  case  of  recurrent  amblyopia  in  a 
physician  of  fifty-four  years  of  age,  who  invariably  had  an  attack 
resulting  from  the  eating  of  chocolate  in  any  form. 

Food  idiosyncrasies  are  not  infrequently  hereditary,  and  may  affect 
several  members  of  one  family.  They  are  independent  of  ordinary 
dyspeptic  conditions,  and  may  be  present  in  those  whose  digestive 
organs  are  exceptionally  robust.  (See  Idiosyncrasies  and  Dyspepsia, 
p.  569.) 

X.  Alcohol  Poisoning  —  Alcoholism  —  Delirium  Tremens 

(Tito  position  of  alcohol  as  both  a  food  and  a  stimulant  is  discussed 

on  pages  ?0-x  2(1(1.) 


ALCOHOLISM  439 

ALCOHOL  POISONING 

The  effects  of  poisoning  by  alcohol  differ  according  as  they  are 
acute  or  chronic,  and  according  to  the  previous  alcoholic  habits  of  the 
patient.  Habitual  drinkers  easily  consume  quantities  of  raw  spirits 
which  might  prove  fatal  if  drunk  by  one  not  inured  to  their  use. 
Men  have  been  known  to  drop  dead  a  few  moments  after  quickly 
drinking  a  quart  or  more  of  whisky  on  a  wager.  Although,  according 
to  Professor  Atwater,  two  and  a  half  ounces  of  alcohol  may  be  oxidized 
daily  by  a  person  in  health,  the  continued  use  of  beverages  con- 
taining this  quantity  is  liable  to  produce  chronic  alcoholism  in  any 
one. 

When  alcohol  is  taken  to  excess  as  a  stimulant  its  effects  are  mani- 
fested by  the  increased  mental  excitement  of  intoxication.  There  is 
a  period  of  restlessness,  insomnia,  loss  of  memory,  and  irritability. 
The  stage  of  insensibility  and  final  stupor  or  coma  develops  later  after 
long  taking  large  quantities  of  alcohol.  Patients  suffering  from  alco- 
holic coma  are  always  in  danger  of  heart  failure  from  paralysis  of  that 
organ,  which  forms  no  exception  to  the  general  rule  that  overstimula- 
tion  of  any  muscle  produces  exhaustion  and  paresis.  When  in  this 
condition,  however,  they  are  fortunately  incapacitated  from  making 
any  sudden  or  violent  exertion,  and  in  acute  cases  alcohol  is  eliminated 
with  considerable  rapidity  from  the  various  excretory  organs  of  the 
body. 

The  continued  use  of  strong  spirits,  as  well  as  their  occasional  use 
in  excess,  almost  invariably  results  in  the  establishment  of  chronic 
gastric  catarrh,  which  is  characterized  by  the  formation  of  thick,  ropy 
mucus,  and  thickening  of  the  gastric  mucous  membrane,  with  atrophy 
of  the  gastric  glands.  There  is  always  malfermentation  with  more  or 
less  acidity  and  heartburn  and  considerable  nausea,  especially  in  the 
morning,  when  the  mucus  or  products  of  indigestion  have  accumu- 
lated over  night.  The  effects  of  chronic  alcoholism  upon  the  alimen- 
tary canal  are  chiefly  manifested  in  the  stomach,  although  the  intes- 
tine may  share  in  the  pathological  changes.  This  is  due  to  the  fact 
that  the  alcohol  reaches  the  stomach  in  a  more  concentrated  form,  and 
that  being  very  diffusible  it  is  absorbed  in  part  before  entering  the 
intestine. 

In  addition  to  the  gastric  catarrh  and  inflammation  which  it  may 
produce,  alcohol  gradually  alters  various  viscera,  causing  cirrhosis  of 
the  liver,  nephritis,  chronic  endarteritis,  etc.  Chronic  alcoholism  is 
one  of  the  commonest  causes  of  multiple  neuritis,  chronic  pachy- 
meningitis,  and  myelitis.  The  chronic  toxic  effect  of  alcohol  exerts  a 


440  DISEASES  CAUSED   BY   DIETETIC   ERRORS 

curiously  selective  action,  for  in  some  patients  the  liver  is  affected,  in 
others  the  kidneys,  in  still  others  the  peripheral  nerves  or  the  brain, 
etc.,  while  other  organs  remain  comparatively  normal.  In  others 
many  organs  are  simultaneously  affected. 

In  chronic  alcoholism  the  intense  craving  for  alcohol  in  any  form 
tends  to  weaken  and  overcome  the  will  power  and  debase  the  moral 
nature  of  the  individual,  and  those  who  are  afflicted  by  this  habit  very 
often  drink  periodically  —  that  is,  the  intervals  between  their  ex- 
cesses may  be  prolonged  for  several  weeks  or  months,  during  which 
they  touch  no  alcohol  in  any  form,  and,  indeed,  in  some  cases  they 
may  have  a  positive  loathing  for  it.  The  very  sight  of  it  nauseates 
them.  The  craving  then  returns  and  becomes  so  irresistible  that  if 
they  cannot  obtain  liquor  they  have  been  known  to  drink  cologne  or 
raw  alcohol  from  spirit  lamps,  or  in  any  form  in  which  they 
can  obtain  it.  The  craving  consists  partly  of  a  special  appetite 
for  liquor  in  the  stomach,  and  in  part  of  the  general  irresistible  desire 
of  the  system,  which  is  somewhat  akin  in  its  effect  to  intense  hunger, 
although  the  effect  on  the  will  power  is  more  disastrous. 

The  dietetic  causes  of  inebriety  form  an  interesting  study.  The 
craving  for  alcohol  is  undoubtedly  fostered  in  many  cases  by  monot- 
ony of  diet,  by  ill-prepared  food,  and  the  resulting  catarrh  of  the 
alimentary  canal  and  lack  of  nutrition.  To  meet  the  symptoms  of 
anorexia,  heartburn,  and  weakness  from  malnutrition  "  tonics "  and 
"  bitters "  containing  alcohol  are  resorted  to,  or  alcohol  is  taken 
more  directly  in  the  form  of  strong  spirits.  While  this  may  tem- 
porarily relieve  the  craving  for  stimulation,  it  often  merely  makes  the 
digestive  disturbance  worse  and  increases  the  mental  depression 
of  "  biliousness."  In  such  manner  the  drink  habit  is  easily  estab- 
lished. 

Dietetic  Treatment  of  Mild  Cases. —  In  the  milder  cases  charac* 
terized  by  nervousness,  muscular  tremors,  indigestion,  dyspepsia, 
a  foul  breath,  coated  tongue,  and  urine  loaded  with  urates  or  crys- 
talline deposits,  if  the  patient  can  be  induced  to  stop  all  alcoholic 
drink  and  take  abundant  water  or  alkaline  effervescing  waters  (Vichy, 
Seltzer,  Apollinaris,  etc.),  together  with  a  proper  diet,  much  can  be 
done  to  ward  off  an  acute  attack.  A  very  good  example  of  the  appro- 
priate diet  is  the  following  from  "  Foods  and  Dietaries  ": 

"  Breakfast. —  A  lightly  boiled  egg,  a  little  whitefish  or  bacon,  or  a 
light  savory  omelet;  toast,  or  bread  and  butter;  a  cup  of  weak  tea  or 
of  coffee  and  milk. 

"Early  Dinner,  1  o'clock. —  A  slice  of  roast  mutton,  the  wing  of 
a  chicken  or  a  plain  cutlet,  with  a  spoonful  of  mashed  potato  and  some 


ALCOHOLISM  441 

well-boiled  green  vegetable.  A  few  spoonfuls  of  any  plain  milk  or 
bread  pudding,  with  occasionally  some  stewed  fruit.  Beverage. —  A 
glass  of  plain  or  aerated  water,  to  be  taken  slowly  towards  the  close  of 
the  meal. 

"  Afternoon. —  A  cup  of  tea  with  milk  may  be  allowed,  with  toast 
or  rusk. 

"Supper,  7.30. —  A  light  meal  of  fresh  fish,  bird,  calf's  head,  or 
tripe,  with  dry  boiled  rice  or  bread.  Beverage. —  Small  glass  of  milk 
and  soda  water." 

In  cases  of  periodic  alcoholism,  in  which  the  patient  has  no  crav- 
ing for  drink  between  his  attacks,  it  is  best  to  recommend  for  the 
intervals  a  nonstimulating  diet,  avoiding  condiments  and  richly 
cooked  or  highly  seasoned  food  of  all  sorts.  Fruits,  plainly  cooked 
cereals,  and  vegetables  should  constitute  the  staple  diet,  and  animal 
food  should  be  eaten  in  moderation,  for  in  some  of  these  cases  over- 
indulgence in  food  excites  the  craving  for  alcohol. 

Dietetic  Treatment  of  Serious  Cases. —  The  treatment  of  the  se- 
verer cases,  in  which  dyspeptic  or  gastrointestinal  symptoms  predom- 
inate, but  in  which  delirium  tremens  is  not  necessarily  present,  is 
mainly  that  of  gastric  catarrh,  described  on  page  587.  It  must  be 
adapted  to  the  degree  of  inflammatory  or  cirrhotic  changes  which  have 
already  taken  place  in  the  different  organs.  The  patients  usually 
feel  much  worse  in  the  mornings,  having  nausea  and  vomiting  or 
loathing  for  food,  but  later  in  the  day  they  may  recover  considerable 
appetite  and  power  of  digestion.  Advantage  should  be  taken  of  this 
fact  in  feeding  them.  The  following  menu  from  "  Foods  and  Dieta- 
ries "  is  well  adapted  to  this  stage  of  chronic  alcoholism : 

"  Breakfast,  say  8  o'clock. —  A  cup  of  weak  tea  with  an  egg  beaten 
up  in  it,  and  a  slice  of  toast. 

"  Second  Meal,  10.30. —  A  cupful  of  good  meat  soup,  thickened,  or 
a  cup  of  peptonized  milk,  warmed,  with  toast  or  rusk. 

"  Early  Dinner,  1  o'clock. —  A  tablespoonful  of-  pounded  meat  on 
toast,  or  a  small  teacupful  of  fresh  meat  juice,  with  fingers  of  toast. 
A  couple  of  spoonfuls  of  sago,  custard,  or  tapioca  pudding.  'Bever- 
age.—  Half  a  tumblerful  of  milk  and  soda  water  (equal  parts). 

"  Afternoon  Tea,  4.30. —  A  cup  of  weak  tea  or  of  cocoa  nibs,  with 
rusk  or  a  plain  biscuit. 

"  Evening  Meal,  7  o'clock. —  A  cup  of  soup  or  of  mutton  broth,  as 
at  the  forenoon  meal. 

"  9.30  or  10. —  A  cup  of  peptonized  milk  and  a  slice  of  thin  bread 
and  butter. 

"Food  During  the  Night. —  In  case  of  wakefulness  there  should  be 


442  DISEASES  CAUSED  BY   DIETETIC   ERRORS 

within  reach,  and  arranged  so  as  to  be  readily  wanned,  peptonized 
milk." 

DELIRIUM  TREMENS 

Delirium  tremens  is  a  condition  of  active  maniacal  excitement 
which  in  its  worst  form  is  accompanied  by  intense  general  nervous 
excitement,  muscular  weakness,  and  hallucinations,  chiefly  of  sight 
and  hearing,  of  a  terrifying  or  disgusting  nature.  It  is  sometimes 
excited  by  a  temporary  debauch,  but  as  a  rule  this  results  in  a  condi- 
tion of  coma  rather  than  maniacal  excitement.  It  is  much  more  char- 
acteristic of  chronic  than  of  acute  alcoholism. 

In  the  earlier  stages  the  heart  action  may  be  apparently  vigorous 
and  the  pulse  full  and  bounding,  but  the  heart  may  become  suddenly 
exhausted  and  cardiac  failure  is  the  chief  danger. 

Dietetic  Treatment. —  The  indications  for  dietetic  treatment  are 
to  make  sure  that  the  alimentary  canal,  which  previously  has  been 
disordered  and  congested,  if  not  inflamed  by  the  excessive  irritation 
of  strong  alcoholic  drink,  is  emptied  of  any  accumulation  of  abnor- 
mally fermenting  food.  In  the  earlier  stages  brisk  purgation  or  an 
evacuant  enema  should  be  given.  If  the  stomach  is  overloaded  with 
improper  food,  free  vomiting  should  be  produced  by  ipecac  or  apo- 
morphine,  provided  the  condition  of  the  patient  is  sufficiently  vigor- 
ous to  warrant  this  procedure.  Large  draughts  of  water,  aerated 
and  saline  waters,  should  be  taken  to  promote  the  activity  of  the 
kidneys  and  to  dilute  the  poison  in  the  system.  The  alimentary  canal 
having  thus  been  emptied  of  fermentation  products,  it  becomes  nec- 
essary to  support  the  patient's  strength  with  abundant  nourishment. 
The  appetite  for  food  is  usually  entirely  absent,  being  replaced  by 
that  for  drink,  but  the  patient  should  be  made  to  take  all  the  nourish- 
ment possible,  and  to  this  end  it  should  be  given  in  fluid  form  in  small 
frequent  doses.  The  food  should  be  stimulating  and  predigested. 
If  there  is  much  gastrointestinal  irritation,  pancreatinized  milk, 
strong  meat  soups,  beef  tea  with  dropped  eggs  added  to  it,  and  egg 
albumin  may  all  be  given.  The  mucous  surface  of  the  stomach  has 
long  been  accustomed  to  the  stimulating  effect  of  strong  alcohol, 
and  if  this  be  suddenly  and  completely  removed,  gastric  discomfort 
and  craving  for  drink  become  intolerable.  This  condition  is  often 
relieved  by  using  strong  spices  or  condiments,  such  as  ginger  or 
Cayenne  popper,  in  quantities  which  would  be  injurious  to  a  normal 
stomach,  and  might  possibly  produce  gastritis.  These  substances 
may  be  added  to  food  and  non-alcoholic  drink,  although  the  stomach 
may  be  actively  inflamed.  Experience  proves  that  highly  seasoned 


ALCOHOLISM  443 

food  is  sometimes  borne  with  the  effect  of  diminishing  the  suffering 
of  the  patient.  This  applies,  of  course,  only  to  robust  patients,  in 
whom  an  otherwise  vigorous  constitution  has  been  abused  by  excessive 
indulgence  in  drink,  and  the  gastric  stimulant  should  not  be  long 
continued.  In  this  variety  of  cases  the  quantity  of  food  which  the 
patient  is  encouraged  to  take  need  be  limited  only  by  the  ability  to 
digest  it.  The  nervous  system  is  always  strengthened  and  soothed  by 
abundant  nourishment. 

Ginger  ale  constitutes  a  very  serviceable  non-alcoholic  beverage, 
which  in  part  relieves  the  craving  for  stronger  drink.  It  may  be 
drunk  in  considerable  quantity,  and  it  possesses  the  advantage  of  be- 
ing somewhat  laxative,  diuretic,  and  mildly  stimulating  to  the  stom- 
ach. Care  should  be  taken  to  obtain  a  pure  article,  as  there  is  much 
inferior  ale  in  market. 

It  is  well  known  that  persons  who  for  many  years  have  indulged 
excessively  in  spirituous  drinks  are  liable  to  develop  delirium  tremens 
if  taken  suddenly  ill,  or  if  they  sustain  an  injury  such  as  a  fracture, 
although  they  may  have  drunk  no  liquor  for  many  weeks.  In  such 
cases  the  patient's  life  is  in  serious  danger  and  it  may  be  necessary 
to  give  a  little  alcohol  temporarily  to  maintain  the  accustomed  influ- 
ence. The  conditions  here  to  be  met  are  very  different  from  those 
resulting  from  an  ordinary  debauch,  when  liquor  should  be  withheld 
entirely. 


PART  VII 
ADMINISTEATION   OF   FOOD   FOE   THE   SICK 


METHODS  OF  FEEDING  THE  SICK 

General  Rules 

IN  no  branch  of  her  work  can  the  nurse  be  of  more  service  than 
in  her  ability  to  feed  a  very  sick  patient  properly.  There  are  many 
details  which  can  only  be  mastered  by  extensive  bedside  experience 
and  close  observation,  and  so  much  depends  upon  tact  and  discretion, 
which  can  never  be  learned  from  text-books  or  lectures,  that  it  is  im- 
possible to  formulate  rules  for  feeding  which  shall  cover  all  cases; 
but  the  following  suggestions  will  be  found  applicable  in  many  in- 
stances. 

Miss  Nightingale  wrote  that  "  to  watch  for  the  opinions  which 
the  patient's  stomach  gives,  rather  than  to  read  '  analyses  of  foods,' 
is  the  business  of  all  those  who  have  to  settle  what  the  patient  is  to 
eat  —  perhaps  the  most  important  thing  to  be  provided  for  him  after 
the  air  he  is  to  breathe." 

The  Appetite  in  Illness. —  In  judging  of  the  patient's  appetite  it 
should  be  remembered  that  what  is  supposed  to  be  a  lack  of  desire  for 
food  is  possibly  due  merely  to  defective  cooking,  to  serving  meals  at 
inopportune  moments,  or  to  selecting  food  which  is  not  to  his  liking. 
There  may  be  appetite  enough  for  food,  but  not  for  the  particular 
food  offered,  and  it  is  the  province  of  the  nurse  to  differentiate  such 
matters.  She  should  not  only  save  the  patient  from  physical  exer- 
tion, but  from  the  effort  of  thinking  as  well. 

It  is  the  function  of  the  nurse  to  observe  and  record  all  the  con- 
ditions of  the  patient's  appetite,  digestion,  and  likes  and  dislikes  for 
different  foods,  and  when  her  instructions  have  not  been  specific,  or 
have  not  provided  for  emergencies,  she  should  make  it  a  point  to 
have  them  understood  at  the  next  visit  of  the  physician.  A  thorough 
practical  knowledge  of  dietetics  should  be  the  foundation  of  the 
nurse's  education,  and  this  subject  should  receive  much  more  atten- 
tion in  the  curriculum  of  training  schools  than  is  at  present  bestowed. 

The  nurse  has  a  far  better  opportunity  than  the  physician  to 
judge  of  the  patient's  appetite  and  study  his  whims  and  fancies  in 

444 


METHODS  OF  FEEDING  THE  SICK  445 

regard  to  food,  and  she  should  not  fail  to  report  them  and  under- 
stand very  positively  from  the  physician  in  charge  to  what  extent 
she  is  to  be  permitted  to  humor  them  and  substitute  one  form  of 
food  or  drink  for  another.  Directions  are  apt  to  be  given  too  in- 
definitely to  the  nurse,  and  with  the  best  intentions,  from  lack  of 
instruction,  she  may  neutralize  the  effects  of  medicines  by  overfeed- 
ing, or  by  irregularities  in  feeding  which  disorder  digestion  and  in- 
terfere with  the  action  of  the  drugs,  besides  making  the  patient 
worse.  She  is  often  merely  told  to  give  "  soft  diet "  or  "  fluid  food," 
and  she  promptly  resorts  to  milk  and  eggs,  which  may  or  may  not 
agree  and  nourish.  Or  instead  of  such  vague  orders  she  may  be  di- 
rected to  give  only  some  one  form  of  food,  which  she  conscientiously 
does,  offering  it  in  spite  of  the  patient's  accumulating  nausea  and 
disgust,  with  the  result  of  half  starving  him,  because  the  physician 
has  forgotten  to  allow  the  nurse  any  latitude  or  discretion.  (See  the 
section  on  Normal  Appetite,  p.  368.) 

Regularity  in  Feeding-. —  The  nurse  should  be  taught  that  it  is 
as  important  to  give  food  as  medicines  at  regularly  appointed  inter- 
vals. Punctuality  should  be  carefully  observed  in  serving  all  meals 
to  the  sick.  There  is  much  unconscious  habit  in  regard  to  eating, 
and  an  appetite  which  was  ready  at  the  accustomed  hour  o-f  receiving 
food  may  vanish  if  the  meal  be  delayed.  It  is  well,  when  possible, 
to  bathe  the  patient's  face  and  hands  before  offering  a  meal.  It  is 
best  always  for  the  same  nurse  to  have  the  charge  of  feeding  a  definite 
number  of  hospital  patients.  If  they  are  served  by  a  different  nurse 
at  each  meal  it  is  much  more  difficult  to  report  those  whose  appetites 
are  defective  or  capricious. 

Quantity  of  Food  in  Illness. —  Among  the  first  considerations  is 
the  proper  quantity  of  food  to  offer  the  sick,  and  the  extent  of  its  dilu- 
tion. Miss  Nightingale  has  said  that  "  an  almost  universal  error 
among  nurses  is  the  bulk  of  the  food,  and  especially  of  the  drinks, 
they  offer  to  their  patients,"  and  "  it  requires  very  nice  observation 
and  care  (and  meets  with  hardly  any)  to  determine  what  will  not  be 
too  thick  or  strong  for  the  patient  to  take,  while  giving  him  no  more 
than  the  bulk  that  he  is  able  to  swallow." 

By  diluting  milk,  stimulants,  and  gruels  too  much,  or  making  beef 
tea  too  weak,  the  quantity  of  the  fluid  is  so  great  that  the  patient 
soon  tires  of  swallowing,  and  stops  before  enough  nourishment  has 
been  obtained.  Predigested  milk  possesses  the  decided  advantage  that 
it  aids  the  assimilation  of  the  milk  without  adding  to  its  bulk,  as  lime 
water  and  other  substances  do. 

When  the  appetite  flags  it  is  unwise  to  ask  the  patient  each  time 


beforehand  what  he  would  like  to  eat.  It  is  often  the  unexpected 
which  pleases.  The  smell  of-  cooking  and  the  noise  of  the  prepara- 
tion of  food  should  be  kept  from  the  sick-room.  The  nurse  should 
never  eat  her  own  meals  in  the  presence  of  the  patient.  (See  Quan- 
tity of  Food,  pp.  327,  328.) 

Details  of  Serving  Food. —  Hot  food  should  be  served  very  hot 
and  cold  articles  very  cold,  for  lukewarm  food  is  unpalatable.  In 
serving  hot  beverages  or  foods  the  cups  or  plates  should  first  be 
well  heated.  Milk  and  butter  should  be  kept  cold  and  well  covered. 
A  simple  refrigerator  is  easily  improvised  by  placing  a  few  large 
lumps  of  ice  in  a  dish  pan  or  pail  kept  by  an  open  shaded  window, 
and  wrapping  them  in  flannel  to  prevent  evaporation. 

Patients  may  appear  too  ill  to  notice  details,  whereas  they  are  often 
merely  too  ill  to  speak  of  them,  and  a  refined,  fastidious,  or  nervous 
patient  may  have  the  appetite  destroyed  by  the  carelessness  of 
a  nurse  who  tastes  the  food  in  the  patient's  presence  or  with  his 
spoon,  or  who  serves  food  with  unclean  hands.  Uneaten  food,  dishes 
after  use,  or  half-emptied  cups  or  glasses  should  never  be  left  stand- 
ing about  the  sick-room.  Nothing  is  more  uninviting  than  to  have 
to  drink  from  a  glass  to  the  sides  of  which  stale  milk  is  adhering. 
If  there  be  any  suspicion  of  the  absolute  freshness  of  milk,  eggs,  but- 
ter, or  fish,  they  never  should  be  served. 

It  is  equally  important  to  make  all  food  look  inviting  by  offering 
it  with  the  most  attractive  china  which  the  house  affords,  and  with 
only  the  cleanest  of  linen.  Dishes  always  should  be  wiped  dry  on 
the  outside,  and  pains  should  be  exercised  not  to  spill  the  contents 
of  cups  into  their  saucers. 

These  may  appear  trivial  details,  but  it  must  be  remembered  that 
the  horizon  of  the  sick-room  is  very  limited,  and  a  patient  who  has 
been  long  confined  to  bed  with  a  serious  illness  thinks  almost  solely  of 
his  immediate  surroundings.  The  taking  of  food  is  the  chief  event 
of  the  day  for  him,  and  too  much  care  cannot  be  bestowed  upon  the 
minutifc  of  service,  while  the  natural  stimuli  to  appetite  —  such  as 
outdoor  air,  exercise,  and  enlivening  companionship  —  are  necessarily 
wanting. 

When  patients  are  able  partially  to  sit  up  for  their  meals,  the 
nurse  should  sec  that  they  have  a  comfortable  position  in  the  bed, 
and  that  the  food  tray  does  not  cramp  the  arms  or  legs.  The  effort 
of  sitting  up  may  cause  fatigue  too  soon  and  destroy  the  appetite 
before  the  meal  is  half  done. 

As  a  rule,  twice-cooked  food  should  not  be  served  to  invalids. 
This  applies  especially  to  meat,  fish,  and  vegetables.  Whenever  econ- 


METHODS  OF  FEEDING  THE  SICK  447 

omy  is  an  important  consideration,  it  is  better  to  cook  little  food  at 
a  time,  and  serve  it  fresh  and  hot.  Food  is  often  made  unpalatable 
by  being  too  greasy,  and  this  is  one  of  the  chief  objections  to  the  use 
of  meat  broths.  Mutton  or  chicken  broths  should  be  several  times 
skimmed  before  they  are  given,  and  blotting  paper  or  a  bit  of 
bread  may  be  passed  over  the  surface  to  remove  the  last  trace  of  oily 
substance.  A  chafing  dish  is  invaluable  for  the  convalescent  from 
protracted  illness. 

When  the  dietary  ordered  is  very  limited  in  variety,  the  patient  is 
often  gratified  by  having  his  food  served  in  "  courses,"  and  will  eat 
more  than  if  given  everything  at  once.  Patients  who  have  been 
fed  long  upon  fluid  foods  exclusively,  are  much  encouraged  by  re- 
ceiving any  solid  food.  It  should  be  remembered  that  junket  and 
baked  custard  are  merely  solid  forms  of  milk  and  eggs,  which  are  no 
less  digestible  than  fluid  forms. 

In  other  cases,  when  a  patient  first  is  allowed  to  sit  up  for  half 
an  hour  or  more  beside  the  bed,  it  may  be  well  to  utilize  this  time 
for  giving  the  principal  meal  of  the  day,  which  will  be  eaten  with 
more  relish,  and  prehaps  better  digested  in  consequence. 

Patients  having  nausea  or  other  gastric  disorder  or  diarrhoea  should 
be  given  only  little  food  at  a  time.  Small,  oft-repeated  feedings  are 
best  for  them.  As  a  rule,  invalids  need  more  salt  as  a  condiment,  but 
less  sugar,  than  those  in  health. 

When  patients  are  being  fed  with  fluids,  different  receptacles  should 
be  used  for  holding  their  medicines,  or  the  association  of  ideas  may 
be  strong  enough  to  destroy  what  little  appetite  there  is,  and  even  to 
produce  nausea. 

The  nurse  should  always  have  a  cheerful  manner  and  a  cleanly 
and  tidy  appearance,  which  contribute  much  towards  the  patient's 
appetite.  She  should  never  offer  nourishment  too  soon  after  remov- 
ing the  vessels  employed  for  the  patient's  discharges  or  evacuations, 
but  should  allow  a  proper  interval  to  elapse,  and  let  it  be  evident  that 
she  has  thoroughly  cleansed  her  hands.  No  form  of  perfumery  should 
ever  be  used  by  the  nurse.  Bread  crumbs  should  never  be  allowed  to 
fall  into  the  bed,  especially  of  a  helpless  patient. 

When  possible,  it  is  well  to  divert  the  patient's  mind  from  his  ail- 
ments while  feeding  him. by  introducing  some  cheerful  or  interesting 
topic. 

Feeding  Helpless  Patients. —  In  feeding  helpless  patients  with 
fluids,  if  the  head  is  to  be  raised,  it  should  be  done  by  placing  the 
hand  beneath  the  pillow  and  lifting  it  gently.  This  affords  much 
better  support,  and  is  more  comfortable  for  the  patient,  for  the  head 


448  ADMINISTRATION   OF  FOOD  FOR  THE   SICK 

is  less  likely  to  be  bent  so  far  forward  as  to  interfere  with  swallowing. 
If  a  tumbler  be  used,  it  should  always  be  small  and  not  more  than 
two-thirds  filled.  An  average  breakfast-cup  holds  eight  fluid  ounces, 
and  an  average  teacup  six  fluid  ounces.  A  thirsty  patient  derives 
more  satisfaction  from  draining  a  small  glass  than  from  sipping  from 
a  large  one  which  he  is  not  allowed  to  empty.  The  feeble  patient 
should  not  be  allowed  to  swallow  during  inspiration,  and  the  nurse 
should  be  careful  that  each  mouthful  is  swallowed  before  another  is 
given,  to  prevent  serious  coughing. 

When  a  glass  tube  is  used  for  feeding,  it  should  have  a  flattened 
end  to  hold  in  the  mouth,  and  should  be  bent  near  the  center  at  a 
slight  angle,  so  that  it  is  unnecessary  to  flex  the  patient's  head.  If 
feeding-cups  with  spouts  are  employed,  they  should  be  of  glass,  so 
that  the  nurse  can  see  how  much  the  patient  is  taking ;  otherwise  fluid 
is  likely  to  be  poured  into  the  mouth  in  too  large  a  quantity.  As  a 
rule,  the  bent  tube  is  decidedly  better  to  use  when  the  patient  has  any 
power  of  suction  at  all.  Even  when  he  has  not,  the  tumbler  or  cup 
may  be  raised  by  the  nurse,  so  that  the  fluid  flows  into  the  mouth 
without  effort.  The  cup  and  tube  should  be  prevented  from  dripping. 

Sleep  and  Feeding. —  Patients  need  only  be  aroused  from  sleep  to 
take  nourishment  in  serious  cases.  Usually  the  ease  with  which  a 
patient  drops  asleep  should  determine  the  necessity  for  awakening 
him.  Sleep  frequently  is  more  beneficial  than  food,  but  there  are  cases 
in  which  a  patient  awakens  to  take  a  sip  of  milk  or  a  few  mouthf uls  of 
food,  and  will  immediately  drop  off  to  sleep  again.  Such  patients 
may  be  aroused  for  food  every  two  hours  if  there  is  need,  as  there  may 
be  in  typhoid  fever.  Some  patients  are  annoyed  by  awakening  at 
three  or  four  o'clock  in  the  morning,  not  being  able  to  sleep  again. 
Food  of  some  sort  should  be  kept  on  hand  during  the  night,  for  drink- 
ing a  cup  of  hot  bouillon  or  cocoa  will  often  enable  them  to  fall 
asleep  again  for  two  or  three  hours.  (The  use  of  the  vacuum  bottle 
for  this  purpose  is  described  on  p.  356.) 

Cleansing  the  Mouth. —  The  patient's  comfort  is  very  dependent 
upon  keeping  a  clean  mouth,  aa  indeed  are  his  appetite  and  sense  of 
taste.  A  helpless  patient  whose  mouth  and  lips  are  allowed  to  become 
parched  and  sour  will  refuse  nourishment  which  he  might  otherwise 
gladly  take.  The  mouth  should  be  rinsed  each  time  after  eating 
with  pure  water,  hydrogen  peroxid  (diluted  one-half),  or  diluted  Lis- 
terine  (four  tablcspoonfuls  to  the  tumbler  of  water),  or  boric  acid 
water  of  saturated  strength.  It  is  much  easier  to  keep  the  mouth  clean 
in  tliis  manner  than  to  disinfect  it  after  it  has  been  neglected.  Milk 
especially  lingers  on  the  mucous  surface,  and,  fermenting  there,  de- 


METHODS  OF  FEEDING  THE  SICK  449 

stroys  the  sense  of  taste  and  develops  germs  that  interfere  with  diges- 
tion. When  the  patient  cannot  rinse  his  own  mouth,  it  should  be 
cleansed  frequently  by  the  nurse  with  a  swab  of  fresh  cotton  fastened 
on  a  small  flexible  stick,  such  as  a  piece  of  splint,  and  moistened  with 
the  mouth  wash.  The  best  tongue  scraper  is  made  with  a  piece  of 
whalebone,  about  nine  inches  long,  bent  into  a  loop.  If  this  be  applied 
before  the  patient's  meals,  the  taste  nerves  of  the  tongue  will  be  uncov- 
ered from  the  accumulated  debris  which  coats  them,  and  the  appetite 
will  be  improved.  Dry  lips  should  be  moistened  with  vaseline  or  cold 
cream,  not  glycerin.  Small  pieces  of  cracked  ice  may  be  given. 
Cracked  ice  will  keep  much  longer  if  not  allowed  to  float  in  melting 
water.  The  contact  of  a  metal  spoon,  or  dish  also  melts  it  sooner,  by 
virtue  of  the  great  conductivity  of  metal.  A  piece  of  cheese  cloth, 
mosquito  netting,  or  linen  may  be  tied  over  a  cup  by  an  elastic  band, 
and  the  fragments  of  ice  split  off  with  a  pin  may  be  laid  upon  the 
cloth,  so  that  the  melted  fluid  drains  away  beneath. 

Disinfection  of  Utensils. —  All  dishes  or  utensils  used  in  serving 
food  to  patients  having  syphilis,  stomatitis,  erysipelas,  diphtheria,  ty- 
phoid fever  or  any  other  infectious  disease  likely  to  be  communicated 
through  the  mouth  or  by  handling  should  be  boiled  for  at  least  half  an 
hour  in  water  containing  a  few  teaspoonfuls  of  soda.  Syphilitic  pa- 
tients, especially,  should  have  their  own  set  of  food  receptacles,  spoons, 
forks,  etc.,  properly  labeled,  to  prevent  any  one  else  from  using  them. 
For  napkins,  cheese  cloth  or  tissue  paper  should  be  used,  which  may  be 
burned. 

Feeding  Unconscious  Patients. —  The  feeding  of  unconscious  and 
delirious  patients  demands  special  care  and  skill.  They  never  should 
be  given  anything  but  fluid  nourishment,  and  this  should  be  fed  with 
a  spoon  or  through  a  catheter.  Sometimes,  if  the  jaw  is  set,  a  medi- 
cine dropper  may  be  utilized.  Not  over  a  teaspoonful  should  be  given 
at  once,  and  the  nurse  must  make  sure  that  it  is  swallowed  before  she 
repeats  the  experiment.  It  should  be  remembered  that  the  mechan- 
ism of  deglutition  is  not  excited  by  one  or  two  drops  of  fluid,  but 
usually  at  least  half  a  drachm  is  required  to  start  this  reflex.  In 
feeding  comatose  infants  or  children  with  tubercular  meningitis,  apo- 
plexy, etc.,  fluid  may  be  poured  into  the  nostril  with  a  spoon  rather 
than  into  the  mouth.  It  disturbs  the  child  less  than  does  the  effort  to 
force  open  the  mouth,  and  if  the  head  is  lying  back  the  fluid  trickles 
down  the  posterior  pharyngeal  wall.  Any  excess  of  fluid  is  returned 
through  the  other  nostril.  There  is  no  greater  danger  of  choking 
when  fed  by  this  method  than  by  the  mouth.  It  is  usually  better, 
however,  to  use  a  soft  catheter  with  a  funnel  attached  to  the  free  end. 
31 


450 


ADMINISTRATION   OF   FOOD   FOR  THE   SICK 


The  catheter  is  oiled  or  dipped  in  vaseline  or  butter,  and  passed  gently 
through  the  nostril  down  into  the  oesophagus,  or,  if  desired,  into  the 
stomach.  Before  pouring  any  fluid  into  it  through  the  funnel  it 
should  be  made  certain  that  the  patient  is  breathing  easily,  and  that 
the  tube  has  not  made  a  false  passage  into  the  larynx.  Such  an  acci- 
dent is  very  rare.  (See  also  Lavage  on  p.  598.) 

Gavage,  or  feeding  with  the  stomach  tube,  is  described  under  that 
heading  on  p.  — .  Nasal  feeding  is  employed  sometimes  as  gavage 
in  young  infants,  in  feeding  children  with  diphtheria,  or  the  insane, 
who  may  refuse  food  or  resist  the  passage  of  a  tube  through  the  mouth 
by  biting,  and  it  may  be  used  when  the  mouth  is  sore  from  ulceration 
or  the  effect  of  corrosive  poisons. 

When  patients  are  living  upon  "  teacup  diet,"  or  broths  and  gruels, 
it  is  a  common  mistake  to  give  them  a  diet  which  is  either  too  low 
in  carbohydrates  or  deficient  in  protein.  The  proper  proportions  to 
be  prescribed,  unless  there  is  some  special  indication  for  the  con- 
trary, will  be  appreciated  by  a  comparison  of  the  following  table, 
compiled  by  Mrs .  E.  H.  Eichards,  and  those  previously  given 
on  p.  327. 

A  Common  Invalid  Ration  Too  Low  in  Carbohydrates    (Mrs.   Richards). 


Protein. 

Fat. 

Carbo- 
hydrates. 

Calories. 

1  pint  of  beef  juice,  containing  7  per  cent.  . 
1  pint  of  whole  milk     

Grams. 

31.5 

17.0 

Grams. 

is!6 

Grams. 

22 

129.0 
325.5 

I  quart  of  flour  gruel  made  with  whole  milk 

18.2 

18.2 

38 

397.9 

2  quarts  of  liquid.     Total          

66.7 

36.2 

60 

852.4 

Nutrient  Enemata 

Rectal  Absorption. —  That  all  mucous  membranes  are  capable  of 
absorbing  certain  materials  from  their  surfaces  and  passing  them 
into  the  blood  vessels  or  lymphatics  has  long  been  recognized;  but 
it  is  only  of  comparatively  recent  years  that  this  knowledge  has  been 
applied  extensively  to  the  purpose  of  nourishing  patients  by  means 
of  the  rectum,  and  the  fact  is  now  established  that  sufficient  aliment 
may  be  absorbed  from  the  mucous  membrane  of  the  rectum  or  sig- 
moid  flexure  alone  to  sustain  life  for  a  considerable  period,  amount- 
ing in  some  cases  to  from  four  to  seven  weeks.  Moreover,  the  rectum 
may  lie  utilixcd  for  accessory  feeding  for  many  cases  in  which  the 
stomach  is  able  to  digest  some  food,  but  not  in  sufficient  quantity  to 
prevent  emaciation. 


METHODS  OF   FEEDING  THE  SICK  451 

Whenever  rectal  food  enemata  are  employed  certain  principles 
should  be  observed: 

1.  The  rectal  surface  should  be  cleansed  from  all  mucus  and  feces. 

2.  Irritation  of  the  rectum  should  be  allayed  as  far  as  possible. 

3.  The  quantity  and  quality  of  food  thus  administered  should  be 
so  regulated  as  to  avoid  exciting  peristalsis,  and  allow  of  the  complete 
absorption  of  one  injection  before  another  is  given. 

The  minutest  details  which  will  secure  the  best  conditions  for  ab- 
sorption should  never  be  regarded  as  too  insignificant.  Some  patients 
find  the  idea  of  rectal  feeding  very  repulsive,  and  dislike  to  submit  to 
it;  but  with  a  little  tact  and' perseverance  their  objections  usually  may 

be  overcome. 

; 

CONDITIONS   DEMANDING  RECTAL  FEEDING 

The  conditions  which  may  require  the  use  of  rectal  feeding  are  as 
follows : 

I.  Temporary  obstruction  to  the  entrance  of  food  into  the  alimen- 
tary canal.     Eectal  feeding  should  be  resorted  to  until  the  obstruc- 
tion —  such  as  the  presence  of  new  growths  and  foreign  bodies,  or 
inflammatory  conditions  with   swelling  in  the  mouth,  pharynx,  or 
resophagus  —  can  be  overcome. 

II.  Inability  to  swallow  food  from  coma,  delirium,  or  paralysis 
affecting  the  mechanism  of  deglutition,  as,  for  example,  post-diph- 
theritic paralysis,  and  tubercular  laryngitis. 

III.  Extreme  irritability,  pain,  acute  inflammation  or  ulceration 
of  the  upper  portion  of  the  alimentary  canal,  such  as  that  excited  by 
corrosive  poisons  like  carbolic  acid,  ammonia,  etc. 

IV.  Stricture  occurring  in  any  part  of  the  alimentary  canal  above 
the  rectum. 

V.  Prolonged  reflex  vomiting,   such  as  may  occur   in  pregnancy 
and  seasickness. 

YI.  Gastric  ulcer,  for  the  purpose  of  resting  the  ulcerated  surface 
and  allowing  it  to  heal. 

VII.  Cancer  of  the  stomach  with  inability  to  absorb  or  digest  suffi- 
cient food,  especially  with  obstruction  to  either  the  cardiac  or  pyloric 
end  of  the  organ. 

VIII.  Any  form  of  severe  gastric  irritation,  such  as  occurs  in  acute 
gastritis. 

IX.  Exhausted  conditions  of  the  system  which  may  be  present  dur- 
ing the  course  of  grave  fevers  in  which  absorption  of  even  predigested 
food  is  largely  suspended. 

X.  For  the  insane  who  refuse  food  bv  the  mouth. 


452  ADMINISTRATION   OF  FOOD  FOR  THE   SICK 

XI.  To  supplement  the  action  of  a  feeble  stomach,  or  when  for 
any  reason,  such  as  total  lack  of  appetite,  emaciation  is  rapidly  pro- 
gressive. 

Hunger  and  Thirst  During  Rectal  Feeding. —  These  symptoms  are 
not  necessarily  present  after  the  first  day  or  two  of  rectal  feeding. 
In  an  obstinate  case  of  gastric  hemorrhage  in  which  absolutely  noth- 
ing—  not  even  water  —  was  given  by  the  mouth  for  more  than  a 
week,  I  questioned  the  patient  in  regard  to  her  sensations  of  hunger 
and  thirst,  and  she  told  me  that  they  were  entirely  relieved  after  the 
first  twenty-four  hours'  use  of  nutrient  enemata.  The  mouth  and 
tongue  were  not  dry,  and  she  did  not  lose  weight  during  this  period. 
I  have  been  told  the  same  thing  by  other  patients. 

An  interesting  case  was  reported  by  C.  W.  Brown,  of  Washing- 
ton, in  which  a  patient  suffering  from  carcinoma  with  ulceration  of 
the  pyloric  end  of  the  stomach  was  supported  for  forty-three  days 
upon  exclusive  rectal  nourishment  consisting  of  from  four  to  six 
ounces  of  beef  tea  and  milk,  which  were  given  on  an  average  once  in 
three  hours,  with  the  occasional  addition  of  laudanum  and  a  little 
whisky.  During  an  interval  of  improvement  which  followed  the 
exclusive  use  of  injections,  the  patient  was  able  to  take  some  food 
by  the  stomach,  though  not  enough  to  satisfy  the  craving  of  hunger 
and  prevent  a  feeling  of  faintness ;  but  these  symptoms  were  overcome 
by  giving  four  nutrient  injections  daily  in  addition  to  the  milk  taken 
by  the  stomach. 

Method  of  Injection. —  The  common  practice  of  giving  nutrient 
enemata  by  a  Davidson  syringe  with  a  short  hard-rubber  or  steel 
nozzle  is  to  be  condemned.  In  the  hands  of  an  unskillful  nurse,  ir- 
ritation, and  sometimes  hemorrhages  are  likely  to  be  produced  in  this 
way,  sooner  or  later. 

In  commencing  the  use  of  rectal  alimentation,  especially  in  cases 
which  manifest  much  irritation  of  the  lower  bowel,  it  is  important 
to  employ  a  long,  soft,  flexible  rubber  catheter  or  rectal  tube,  which 
can  be  passed  well  in,  for  eight  inches  or  more,  to  the  sigmoid 
flexure.  In  selecting  the  tube,  one  should  be  chosen  which  is  not 
so  flexible  that  it  is  liable  to  bend  or  double  upon  itself,  but  which 
is  not  so  stiff  as  to  give  pain  or  damage  the 'mucous  membrane  if 
it  happens  to  catch  in  a  fold  of  its  surface.  For  children  a  No.  12 
or  Xo.  14  ordinary  "velvet-eyed"  flexible  catheter  may  be  used,  and 
passed  as  high  as  the  sigmoid  flexure.  For  adults  the  tube  should  be 
of  moderate  caliber,  not  exceeding  the  diameter  of  a  stout  pen  handle. 
The  tubo  or  catheter  should  be  dipped  in  sweet  oil,  melted  butter,  or 
vaseline;  but  glycerin  should  not  be  used,  for  it  excites  peristalsis. 


METHODS  OF  FEEDING  THE  SICK  453 

In  adults  the  tube  should  be  passed  in  from  ten  to  twelve  inches, 
for  the  injection  should  be  placed  up  as  high  as  possible.  When  this 
is  done  there  is  less  liability  to  its  rejection,  and  it  is  brought  in  con- 
tact with  an  extensive  mucous  surface.  There  is  a  further  physiolog- 
ical or  anatomical  reason  for  placing  the  injection  as  far  up  as  may 
be,  in  the  fact  that  the  sigmoid  veins  and  those  returning  the  blood 
from  the  upper  rectum  communicate  with  the  inferior  mesenteric 
vein,  while  those  from  the  lower  third  of  the  rectum  communicate  with 
the  inferior  vena  cava.  Consequently,  whatever  is  absorbed  by  the 
wall  of  the  inferior  third  of  the  rectum  passes  into  the  inferior  vena 
cava  without  going  to  the  liver,  but  that  which  is  absorbed  farther 
up  is  absorbed  by  veins  whose  contents  reach  the  liver  directly  through 
branches  of  the  vena  porta.  It  is  in  the  liver  that  the  further 
assimilation  of  protein  takes  place  in  great  part,  and  hence  the  desira- 
bility of  observing  this  rule. 

It  was  found  by  Brown,  in  the  case  above  cited  (p.  452),  that  the 
patient  was  able  to  discriminate  between  the  taste  of  iodide  of  potas- 
sium and  ergot,  etc.,  in  from  a  quarter  to  half  an  hour  after  those 
medicines  had  been  given  per  rectum.  The  same  phenomenon  has 
been  noticed  from  the  injection  of  such  substances  directly  into  the 
stomach  through  a  gastric  fistula,  and  it  is  due  to  their  ready  absorp- 
tion and  conveyance  in  the  blood  to  the  taste  bulbs  in  the  tongue  or  to 
the  saliva,  in  which  fluid  the  iodide  of  potassium  is  promptly  excreted. 

According  to  some  observers,  under  the  best  conditions  not  over 
one-fourth  of  the  necessary  nutriment  can  be  absorbed  from  the 
rectum  (Bauer).  Such  a  statement  should  be  considerably  modified, 
for,  as  a  matter  of  practical  experience,  many  patients  may  be  kept 
alive  and  gain  slightly  in  weight  upon  the  use  of  nutrient  enemata, 
when  they  are  intelligently  given.  If  injected  but  a  short  distance 
into  the  rectum,  the  absorbing  surface  is  so  limited  that  compara- 
tively little  material  is  taken  up;  but  if  given  in  the  manner  pre- 
scribed above,  much  more  will  be  retained. 

The  injection  should  be  applied  by  means  of  a  small  hard-rubber 
syringe,  which  need  not  hold  over  four  ounces.  Very  little  force 
should  be  used,  and  the  patient  told  not  to  strain.  After  the  syringe 
is  filled,  by  holding  it  vertically  nozzle  uppermost  and  pressing  it 
until  the  fluid  exudes  from  the  nozzle,  all  air  is  excluded.  When  a 
Davidson  syringe  is  used  for  the  purpose  of  injecting  small  quantities 
of  fluid,  it  very  often  happens  that  air  is  drawn  into  the  syringe  in 
addition  to  the  materials  of  the  enema,  which,  when  injected,  is  lia- 
ble to  excite  peristalsis  and  evacuate  the  bowel.  The  use  in  unskill- 
ful hands  of  a  funnel  or  fountain,  syringe  for  filling  the  tube  is  open 


454 

to  the  same  objection  —  that  air  is  likely  to  enter  the  rectum.  In  any 
case  it  is  well  to  fill  the  tube  with  the  injection  fluid  before  it  is 
inserted. 

Quantity. —  The  proper  quantity  of  food  for  a  nutrient  enema  for 
an  adult  is  4  to  6  ounces;  for  a  young  child,  2  to  3  ounces,  given 
every  four  to  six  hours. 

Aids  to  Retention. —  Upon  withdrawing  the  tube,  if  there  is  danger 
that  the  injection  may  not  be  retained,  a  soft  compress  or  folded  towel 
should  be  pressed  up  firmly  against  the  anus  for  twenty  minutes  or 
half  an  hour. 

The  retention  of  the  enema  is  aided  by  placing  the  patient  in  a 
proper  position.  He  should  lie,  if  possible,  upon  the  left  side,  with 
the  hips  raised  high  upon  a  pillow,  and  the  injection  should  be  given 
very  slowly  and  carefully.  The  "  Sims "  gynecological  position  is 
the  best,  but  with  the  hips  more  elevated. 

Temperature  of  Injections. —  All  food  enemata  should  be  given 
moderately  warm,  at  a  temperature  of  90°  or  95°  F.  They  are  less 
likely  to  excite  peristalsis  than  if  administered  very  hot  or  very  cold. 

Number  of  Injections. —  The  question  of  how  many  injections  can 
be  given  depends  upon  the  irritability  of  the  rectum.  It  can  never 
be  used  like  the  stomach,  and  it  is  advisable  to  begin  by  ordering  an 
enema  only  once  in  six  hours.  If  the  rectum  is  in  good  condition  the 
number  may  be  increased  to  one  every  four,  or  even  every  three 
hours. 

Care  of  the  Rectum. —  When  it  is  important  that  nutrient  enemata 
should  be  continued  for  some  time,  the  exact  condition  of  the  rectum 
should  be  ascertained  by  the  physician,  and  the  most  minute  direc- 
tions should  be  given  to  the  nurse. 

As  stated,  many  cases  have  been  recorded  in  which  patients  have 
been  nourished  exclusively  by  nutrient  enemata  for  several  weeks,  and 
it  is  an  important  fact  that  the  rectum  may  acquire  a  certain  degree 
of  toleration  for  them.  For  the  first  few  days  they  may  be  rejected, 
but  when  correctly  prepared  and  administered  they  soon  will  be  re- 
tained successfully.  But  it  is  only  in  the  most  favorable  cases  that 
rectal  alimentation  can  be  long  continued  without  eventually  produc- 
ing irritation  and  mucous  diarrhoea,  and  in  the  majority  of  instances 
this  is  likely  to  occur  after  two  or  three  weeks.  The  enemata  should 
then  be  discontinued,  but  may,  if  necessary,  be  resumed  again  after  a 
brief  interval. 

The  presence  of  hemorrhoids  is  a  serious  drawback  when  the  use 
of  rectal  feeding  becomes  imperative,  and  care  should  be  exercised  not 
to  irritate  or  inflame  them.  In  such  cases  it  is  necessary  to  use  only 


METHODS  OF  FEEDING  THE  SICK  455 

a  very  soft  and  flexible  catheter,  and  to  allay  irritation  by  the  topical 
application  of  a  4-per-cent  solution  of  cocaine. 

Whenever  nutrient  enemata  are  employed  for  a  long  time  the 
rectum  should  be  thoroughly  evacuated  and  cleansed,  at  least  once 
a  day,  by  flushing  with  a  copious  injection  of  warm  soapsuds  and 
water,  amounting  to  two  or  three  pints,  immediately  after  which  a 
food  enema  should  be  given. 

The  cleansing  enemata  may  be  given  through  a  double  or  single 
catheter.  If  a  double  catheter  is  preferred,  a  larger  quantity,  two 
or  three  quarts,  of  water  may  be  given  advantageously,  and  a  drachm 
of  common  salt  should  be  added  to  each  quart.  If  the  rectum  is  irri- 
table, and  much  mucus  coats  its  inner  surface,  it  may  be  well  to  add 
boric  acid  to  the  water  in  saturated  solution.  The  injection  washes 
out  any  particles  of  waste  matter  or  remains  of  a  previous  nutrient 
injection,  cleanses  the  mucous  surface,  stimulates  its  circulation,  and 
prepares  it  for  better  absorption. 

Opium  in  Enemata, —  Opium,  while  it  prevents  peristaltic  action 
and  favors  retention  of  the  enema,  may  tend  also  to  interfere  with 
its  absorption.  It  is  consequently  to  be  avoided,  if  possible,  but  when 
irritation  of  the  rectum  exists  it  becomes  necessary  to  inject  a  little 
laudanum.  Ordinarily,  three  to  four  minims  is  sufficient,  but  ten 
may  be  required  in  some  cases.  This  dosage  should  not  be  repeated 
often,  and  its  effect  should  be  watched.  If  nutrient  enemata  are  con- 
stantly employed  it  is  sometimes  found  that  a  larger  dose  injected 
by  a  small  hard-rubber  syringe  half  an  hour  or  an  hour  before  giving 
an  enema  allays  the  irritation  more  completely  than  if  the  opium  be 
given  with  the  food.  Injected  by  itself,  the  quantity  of  opium  is  so 
small  that  it  is  not  ejected,  but  is  absorbed,  and  its  local  action  is  ob- 
tained before  the  larger  bulk  of  fluid  enema  is  injected.  In  some 
cases  tincture  of  belladonna  (4  or  5  minims)  is  to  be  preferred  to  the 
opium. 

Substances  Available  for  Rectal  Feeding. —  Of  the  different  classes 
of  food  stuffs,  there  are  some  which  are  absorbed  readily  by  the  rec- 
tum, while  others  are  scarcely  taken  up  at  all.  To  the  latter  class 
belong  starches  and  most  of  the  fats.  Those  starches  which  are  pre- 
digested  and  partially  converted  into  sugar  may  be  absorbed  to  a  very 
limited  extent,  but  not  sufficiently  to  add  to  the  nutrition  of  the  body. 
Maltine  may  sometimes  be  absorbed.  Fats  and  oils  not  only  remain 
unabsorbed  by  the  rectum,  but  they  prevent  the  absorption  of  other 
foods  by  coating  either  the  mucous  membrane  or  the  food  itself,  and 
are  therefore  worse  than  useless.  Attempts  have  been  made  to  give 
them  saponified  or  finely  emulsified,  prepared  with  pancreatin  or 


456  ADMINISTRATION   OF  FOOD  FOR  THE   SICK 

otherwise,  but  it  is  doubtful  if  even  under  these  circumstances  enough 
of  any  form  of  fat  or  oil  can  be  taken  up  to  be  of  practical  benefit  in 
rectal  feeding. 

It  is  exceedingly  important  to  use  only  materials  which  will  be 
as  completely  absorbed  as  possible.  Anything  else  acts  as  a  foreign 
body,  and  in  time  proves  more  or  less  irritating.  Moreover,  it  is 
found  that  many  albuminous  materials  which  are  absorbed  from  the 
surface  of  this  portion  of  the  intestine  become  irritating  if  given  in 
too  concentrated  a  form,  such  as  pure  peptone,  and  they  should  be 
diluted  to  two  or  three  times  their  volume  with  water  or  some  bland 
fluid.  Some  forms  of  albumin  are  undoubtedly  absorbed  from  the 
mucous  membrane  of  the  rectum  without  predigestion,  such  as  that 
expressed  from  chopped  meat  or  egg  albumen,  but  it  is  much  better 
to  pancreatinize  it  at  least  partially. 

Pancreatinized  Meat. —  In  preparing  proteid  food  for  absorption 
one  of  the  forms  of  pancreatic  extract  or  pancreal^n  may  be  used. 
(See  p.  398.)  Extracts  of  pancreas  are  open  to  the  objection  that  they 
do  not  keep  very  long,  and  unless  perfectly  fresh  they  are  likely  to 
prove  irritating,  and  glycerin  extracts  cannot  be  used  in  any  quantity 
on  account  of  the  aperient  action  of  the  glycerin  itself.  To  overcome 
these  difficulties,  Leube  suggests  using  the  fresh  pancreas,  which  is 
to  be  added  in  the  proportion  of  one  part  to  three  of  beef.  Both 
the  meat  and  the  pancreatic  gland  should  be  scraped  or  thoroughly 
minced  and  rubbed  into  a  paste  with  a  little  warm  water.  Any  fat 
should  be  carefully  removed.  The  pulp  thus  obtained  is  to  be  in- 
jected by  means  of  a  suitable  syringe  with  a  rather  wide  nozzle.  The 
digestion,  which  is  begun  outside,  is  continued  within  the  rectum. 
Leube  sometimes  adds  egg  albumen  to  the  mixture. 

Sansom  gives  the  following  formula  for  a  meat  peptone  enema 
suitable  for  an  infant  or  young  child :  Shred  raw  beef  or  mutton  in 
bulk  about  two  tablespoonfuls,  add  an  equal  bulk  of  water,  and  let 
stand  for  an  hour;  then  add  gradually  four  tablespoonfuls  of  milk 
heated  to  boiling.  When  all  is  well  mixed  the  temperature  of  the 
mixture  will  be  about  140°  F.,  then  add  a  teaspoonful  of  Savory  & 
Moore's  or  Benger's  liquor  pancreaticus,  and  a  pinch  of  bicarbonate 
of  soda.  Let  the  whole  remain  for  six  hours,  and  heat  to  boiling. 
Strain  through  muslin  and  preserve  the  liquid,  which  will  suffice  for 
several  enemas. 

Blood.—  Dried  lieef  blood  has  been  used  as  a  rectal  food,  but 
there  is  no  evidence  that  it  is  absorbed.  In  those  cases  in  which 
I  have  employee!  it  it  has  usually  caked  within  the  rectum  and  pre- 
vented the  absorption  of  other  materials.  Fresh  defibrinated  blood 


METHODS  OF  FEEDING  THE  SICK  457 

has  also  been  used  for  the  same  purpose  —  four  ounces  may  be  given 
every  six  hours  —  but  it  possesses  no  advantage  over  predigested  niilk 
or  peptones,  and  is  not  to  be  recommended. 

Milk. —  Pancreatinized  milk  in  which  the  process  of  predigestion 
has  not  been  carried  too  far  is,  on  the  whole,  one  of  the  most  satis- 
factory foods  which  can  be  used  by  rectum.  It  should  not  be  rich 
in  cream. 

It  may  be  given  alone  or  with  beef  juice,  beef  peptonoids,  spirits, 
etc.  From  two  to  four  ounces  are  given  at  a  time,  after  cleansing  the 
rectum. 

The  simple  mucous  secretions  of  the  rectum  have  no  proper  diges- 
tive action  upon  milk,  but  they  may  cause  putrefaction  of  its  album- 
inous matter,  with  formation  of  tyrosin,  indol,  etc. 

Eggs. —  Huber  proved  by  experiments  upon  patients  in  nitrogenous 
equilibrium  that  the  rectum  absorbs  25  to  35  per  cent  of  the  nitrogen 
of  raw  eggs,  70  per  cent  from  raw  eggs  with  sodium  chloride,  and  75 
per  cent  from  peptonized  eggs.  The  whites  of  two  eggs  may  be  added 
to  peptonized  milk,  or,  better,  to  peptone  solution  or  one  of  the  meat 
extracts.  Karl  E.  Ewald,  of  Berlin,  who  has  experimented  exten- 
sively with  rectal  alimentation,  states  that  unpeptonized  egg  albumen 
is  absorbed  as  promptly  from  the  rectal  surface  as  commercial  pep- 
tone, while  peptonized  egg  albumen  is  taken  up  better.  The  absorp- 
tion of  albumen  is  furthered  by  the  addition  of  a  little  table  salt  to 
the  injection  —  about  fifteen  grains  to  each  egg. 

The  yolk  of  egg  is  not  recommended  for  rectal  use,  for  although 
it  contains  albuminous  material,  so  much  fat  is  mixed  with  it,  which 
is  not  absorbed,  that  it  is  useless. 

Grape  Sugar. —  Of  the  various  carbohydrates,  it  has  been  proved 
by  Schonborn  that  a  solution  of  glucose  is  best  absorbed.  The  solu- 
tion should  not  be  stronger  than  10  per  cent  in  water,  and  should 
not  be  used  too  often,  as  it  may  prove  irritant  and  excite  diarrhoea. 
As  much  as  95  per  cent  of  such  solution  may  be  absorbed. 

The  addition  of  salt  to  all  forms  of  food  enemata  aids  in  their 
absorption. 

Alcohol. —  The  alcohol  used  for  rectal  injection  should  be  in  the 
form  of  good  liquor,  somewhat  diluted.  If  pure  alcohol  be  given, 
it  should  be  diluted  in  three  or  four  parts  of  water,  when  it  becomes 
less  irritating  to  the  mucous  membrane  and  is  more  easily  absorbed. 
Very  often  a  small  injection  of  half  an  ounce  of  whisky  in  an  ounce 
and  a  half  of  water,  or  even  an  injection  of  whisky,  brandy,  or  rum 
and  water  given  alone,  will  be  retained  and  completely  absorbed, 
when  a  larger  volume  of  fluid  added  to  the  alcohol  will  not  be  re- 
32 


458  ADMINISTRATION   OF  FOOD  FOR  THE   SICK 

tained,  and  the  whole  enema  will  pass  out  again.  When  alcohol  is 
given  in  connection  with  other  rectal  foods,  it  may  be  unnecessary 
to  dilute  it  with  water,  but  undiluted  whisky  may  cause  precipita- 
tion in  milk.  If  added  too  strong  it  coagulates  casein  which  has 
not  been  pancreatinized. 

Prescriptions  for  Food  Enemata. —  Ewald  recommends  the  follow- 
ing :  Beat  the  whites  of  two  eggs  with  a  tablespoonf ul  of  cold  water, 
add  a  teaspoonful  or  two  of  starch  boiled  in  a  half  teacupful  of  a 
20-per-cent  glucose  solution,  a  wineglassful  of  claret  and  a  teaspoon- 
ful of  peptone  solution.  Mix  at  a  temperature  below  the  coagula- 
tion point  of  the  albumen. 

Yeo  prescribes  expressed  meat  juice,  egg  albumen,  and  peptones. 

Leube  prefers  the  mixture  of  scraped  meat  and  fresh  pancreas 
made  into  an  emulsion  as  prescribed  above  (p.  456). 

Eoberts  gives  milk  gruel  and  beef  tea,  with  two  teaspoonfuls  of 
liquor  pancreaticus  freshly  mixed.  He  reports  a  case  in  which  he 
sustained  the  patient's  life  for  nine  weeks  upon  this  treatment  alone. 

I  commonly  give  4  ozs.  of  pancreatinized  milk  with  the  white  of 
two  eggs  and  2  teaspoonfuls  of  milk  sugar,  or  2  ozs.  each  of  beef 
juice  and  milk  pancreatinized. 

Food  Suppositories. —  Rectal  food  suppositories  are  sometimes  made 
of  predigested  and  evaporated  or  condensed  forms  of  milk  or  meat 
juice,  which  are  mixed  with  oil  or  cacao  butter  and  pressed  into  an 
elongated  bougie  or  suppository.  They  occasionally  prove  useful,  and 
are  certainly  convenient,  but  they  possess  no  real  advantage  over 
nutrient  enemata,  and  if  rectal  feeding  is  to  be  long  continued,  the 
latter  are  far  more  practical. 

Other  Methods  of  Feeding 

Inunction  Foods. —  Attempts  are  made  occasionally  to  put  nourish- 
ment into  the  body  by  means  of  inunction  through  the  skin,  and 
olive  oil,  cod-liver  oil,  and  cacao  butter  are  rubbed  into  the  integu- 
ment of  the  abdomen  and  thighs.  This  means  is  employed  naturally 
only  in  cases  of  extreme  emaciation  from  wasting  diseases,  such  as 
carcinoma,  marasmus,  and  phthisis.  It  has  proved  mainly  useful 
with  marasmic  infants,  but  it  is  doubtful  whether  it  possesses  any 
true  value  beyond  the  advantage  of  lubricating  a  dry  and  shriveled 
skin,  and  retaining  some  of  the  body  heat  in  case  of  great  feebleness. 

Intravascular  Feeding. —  In  extreme  cases  of  collapse,  where  death 
lias  seemed  imminent,  nutrient  infusions  have  sometimes  been  given 
directly  into  the  veins.  Of  late  years,  however,  it  has  been  shown 
that  in  collapse  from  hemorrhage,  or  from  loss  of  fluid  in  the  evacua- 


MEDICINES  AND   FOOD  459 

tions  of  Asiatic  cholera  and  cholera  morbus  in  infants,  salt-water  in- 
fusions (a  drachm  to  the  pint)  answer  as  well,  and  have  the  advan- 
tage of  being  much  safer  and  easier  of  application. 

Edward  M.  Hodder,  of  Montreal,  was  the  first  to  practice  the  in- 
travenous injection  of  milk  in  1850  for  collapse  from  Asiatic  cholera, 
and  the  late  T.  G.  Thomas,  of  New  York,  was  among  the  first  to 
inject  warm  milk  into  one  of  the  veins  of  the  arm.  In  1878  he 
reported  seven  cases,  in  one  of  which  eight  ounces  of  milk  administered 
in  this  way  saved  life.  Both  goat's  and  cow's  milk  have  been  so 
used,  and  the  milk  must  be  alkaline.  Down  reports  similar  success. 

Fowler  tried  intravenous  injection  of  peptone  solution,  and  has 
given  as  much  as  six  ounces  of  a  digested  beef  solution  in  this  man- 
ner. The  peptone  does  not  reappear  in  the  urine,  but  the  casein  of 
milk  does,  as  well  as  solutions  of  sugar  or  albumin  when  injected 
into  a  vein.  Some  of  the  fat  droplets  in  milk  have  greater  diameter 
than  the  capillaries,  which  might  prove  a  practical  objection  to  the 
injection  of  unskimmed  milk. 

Hypodermic  Feeding1. —  Feeding  in  cases  of  desperate  exhaustion 
by  hypodermic  injections  of  milk  and  of  peptone  solutions  has  been 
several  times  attempted,  but  the  results,  beyond  the  use  of  alcohol 
by  this  method,  have  not  proved  sufficiently  satisfactory  to  warrant 
its  continuance. 

Bayle  has  employed  the  yolk  of  egg  diluted  with  an  equal  weight 
of  normal  salt  solution  (7:1,000),  giving  three  drachms  at  a  dose. 
Lecithin  has  similarly  been  injected. 

Crede  has  made  use  of  a  preparation,  which  he  calls  "  Kalodol," 
containing  95  per  cent  of  soluble  meat  albumin  and  0.2  per  cent 
of  salt.  He  adds  50  grams  (l1/^  oz.)  of  a  10-per-cent  solution  of 
Kalodol  to  500  c.  c.  (about  one  pint)  of  normal  salt  solution  for 
hypodermoclysis.  This  preparation  is  also  quickly  absorbed  from 
the  rectum.  Van  Leube  has  injected  butter  into  dogs  and  showed 
that  the  fat  was  absorbed  and  consumed. 

MEDICINES  AND  FOOD 

Too  little  attention  has  been  bestowed  upon  the  mutual  relations 
of  food  and  medicines.  So  little  is  really  definitely  known  of  the 
intricate  chemistry  of  digestion  and  assimilation  that  it  is  difficult 
to  formulate  rules  for  the  right  time  of  giving  every  drug  in  rela- 
tion to  fullness  or  emptiness  of  the  stomach.  The  reaction  of  the 
stomach  contents  varies  from  alkaline  to  neutral  and  acid,  and  these 
several  reactions  will  decompose  medicines  in  various  ways.  Besides 


460          ADMINISTRATION   OF  FOOD  FOR  THE   SICK 

this,  the  reactions  themselves  are  dependent  upon  a  large  number  of 
organic  acids,  salts,  and  other  substances  which  may  alter  the  com- 
position of  a  medicine  at  one  time,  and  not  be  present  to  affect  it  at 
another.  A  drug  given  after  a  full  meal  may  be  decomposed  by  the 
hydrochloric  acid  of  active  digestion,  which  is  unaltered  in  an  empty 
stomach.  Conversely,  remedies  which  are  not  themselves  influenced 
by  the  gastric  and  pancreatic  juices  may  affect  these  secretions  as 
synergists  or  the  reverse.  Chittenden  says :  "  Take,  for  example, 
the  influence  of  such  substances  as  urethan,  paraldehyde,  and  thal- 
lin  sulphate  on  the  proteolytic  action  of  pepsin-hydrochloric  acid, 
and  we  find  that  small  quantities  (0.1  to  0.3  per  cent)  tend  to  in- 
crease the  rate  of  proteolysis,  while  larger  amounts,  say  one  per 
cent,  decidedly  check  proteolysis.  Similarly,  among  inorganic  com- 
pounds, arsenous  oxide,  arsenic  oxide,  boric  acid,  and  potassium 
bromide  in  small  amounts  increase  the  proteolytic  power  of  pepsin 
in  hydrochloric-acid  solution,  while  larger  quantities  check  the  action 
of  the  ferment  in  proportion  to  the  amount  added.  Again,  with  the 
enzyme  trypsin,  similar  results  with  such  salts  as  potassium  cyanide, 
sodium  tetraborate,  potassium  bromide  and  iodide  may  be  quoted  as 
showing  not  only  the  sensitiveness  of  the  ferment  towards  foreign 
substances,  but  likewise  its  peculiar  behavior  —  viz.,  stimulation  in 
the  presence  of  larger  quantities.  Furthermore,  we  have  found  that 
even  gases,  as  carbonic-acid  and  hydrogen  sulphide,  exert  a  marked  re- 
tarding influence  on  the  proteid-digestive  power  of  trypsin."  These 
gases,  being  a  product  of  intestinal  malfermentation,  may  thus  in- 
terfere with  digestion. 

Hydronaphthol  and  bismuth  salicylate  retard  gastric  digestion. 
Sodium  bicarbonate  and  other  alkalies  check  pyrosis  in  chronic  gas- 
tritis, which  is  caused  by  diminished  hydrochloric-acid  secretion,  but 
increase  pyrosis  subsequently,  because  of  the  greater  alkalinity  pro- 
duced, which  promotes  the  growth  of  lactic-acid  organisms.  Ac- 
cording to  Leffmann  and  Beam,  beta-naphthol  stops  the  action  of 
diastase,  but  not  that  of  the  amylolytic  ferment  of  pancreatin,  hence 
it  is  useful  as  an  intestinal  antiseptic  without  completely  stopping 
digestion.  It  however  retards  proteid  digestion.  They  also  state 
that  salicylic-acid  and  saccharin  both  prevent  the  amylolytic  action 
of  diastase  and  of  pancreatin,  but  do  not  retard  proteid  digestion. 

These  few  examples  are  sufficient  to  illustrate  the  very  diverse 
influence  of  some  of  the  common  drugs  upon  digestion,  but  the  ef- 
fect of  digestion  upon  the  drugs  is  imperfectly  known. 

The  following  rule?  are  subject  to  many  exceptions,  but  they  may 
serve  a*  a  general  guide : 


MEDICINES  AXD   FOOD  461 

Rules  for  Administering  Medicines  in  Relation  to  Food 

1.  Alkalies  are  best  given  shortly  before  meals,  unless  designed  to 
neutralize  hypersecretion  of  hydrochloric  acid. 

2.  Acids  should  be  given  within  an  hour  after  meals. 

3.  Bitters  should  be  given  before  meals. 

4.  Eemedies  such  as   iron  and   arsenic,  which   may   prove  some- 
what irritant  to  mucous  membranes,   should  be  given  either   soon 
after  the  regular  meals  or  after  taking  some  simple  article  of  food. 
Ammonium  carbonate  and  potassium  iodide,  for  example,  may  be 
prescribed  in  milk. 

5.  Most  cough  medicines,  cardiac  tonics,  diuretics,  and  systemic 
remedies  which  are  not  especially  irritating  to  the  stomach  should 
be  taken  between  meals.     They  will  be  more  promptly  absorbed  from 
an  empty  stomch,  and  are  less  liable  to  be  altered  in  composition 
by  digestive  fluids  or  to  inhibit  digestion. 

6.  Eemedies  designed  to  act  in  the  intestine  and  not  in  the  stomach, 
such  as  salol,  creosote,  naphthol,  etc.,  should  be  given  at  the  end 
of  gastric  digestion,  when  the  stomach  contents  are  about  to  pass 
into  the  intestine. 

7.  Saline  laxatives  always  should  be  taken  at  least  half  an  hour 
or  an  hour  before  meals,  preferably  before  breakfast ;  but  the  stronger, 
more  slowly  acting  cathartics  should  be  given  on  an  empty  stomach 
at  night.     Cod-liver  oil  should  be  given  two  hours  after  meals,  or 
on  an  empty  stomach  before  retiring. 

Amylaceous  food  should  be  avoided  while  iodine  preparations  are 
being  administered,  because  of  the  insoluble  compound  likely  to  be 
formed  of  iodine  and  starch.  Syphilitics  should  therefore  eat  meat 
and  green  vegetables  only,  in  order  to  get  a  maximum  effect  from  the 
remedy,  especially  if  they  are  taking  very  large  quantities,  such  as 
half  an  ounce  or  more  a  day. 

Foods  and  beverages  may  be  used  to  disguise  the  taste  of  dis- 
agreeable or  bitter  medicines,  especially  for  children.  An  unpleas- 
ant dose  may  be  smuggled  down  in  a  teaspoonful  of  jam  or  a  little 
molasses.  •  It  may  be  given  in  solution  to  adults  in  coffee.  Castor 
oil  is  given  floating  on  coffee  or  beer.  Both  milk  and  Vichy  partially 
disguise  the  taste  of  potassium  iodide. 

Hot  milk  is  an  excellent  vehicle  for  insoluble  powders,  such  as  bis- 
muth, magnesium  carbonate,  or  sulphonal.  Many  bitter  medicines 
may  be  followed  by  a  lump  of  sugar  or  a  strong  peppermint  lozenge,  or 
the  mouth  may  be  rinsed  with  a  little  brandy  and  water.  Chocolate  is 
also  a  good  vehicle  for  the  administration  of  bitter  medicines,  siich 


462  ADMINISTRATION   OF   FOOD  FOR  THE   SICK 

as  quinine,  and  it  may  be  employed  to  emulsify  cod-liver  oil,  or  used 
in  the  form  of  lozenges  for  various  medicines. 


DIET-KITCHEN  OUTFIT 

When  a  case  of  protracted  severe  illness  occurs  in  a  household  it 
is  very  convenient  to  improvise  a  small  diet  kitchen  in  a  room  next 
the  patient's  bedroom.  The  outfit  should  consist  of  the  following 
articles,  in  addition  to  the  usual  receptacles  for  containing  the  food: 

A  spirit  or  gas  lamp  kept  ready  to  heat  a  porcelain-lined  sauce- 
pan at  any  time,  day  or  night:  double  porcelain-lined  saucepan  for  a 
hot-water  bath;  cooking  thermometer  for  use  in  hot  fluids;  measur- 
ing glass  to  hold  six  or  eight  ounces;  pancreatin  powders;  bottle  of 
rennet  ferment;  sodium  bicarbonate,  two  or  three  ounces;  borax,  half 
a  pound  (to  clean  utensils);  glass  funnel  with  filter  papers;  meat- 
mincing  machine. 

A  good  chafing-dish  and  a  pair  of  scales,  although  not  necessary, 
are  desirable. 

TRAINED  PURVEYORS  OF  FOOD 

The  training  of  food  purveyors  for  hospitals,  asylums,  and  other 
institutions  has  only  lately  received  the  attention  which  it  deserves, 
and  hospital  managers  are  awakening  to  the  fact  that  it  is  economical 
to  employ  a  skillful  trained  buyer  who  understands  something  of 
food  values,  dietetically  as  well  as  pecuniarily,  and  who  studies  the 
conditions  of  the  market  at  different  seasons  of  the  year  in  order  to 
secure  variety  of  food  at  a  minimum  cost.  To  meet  the  constantly 
increasing  demand  for  such  persons,  the  Pratt  Institute,  of  Brooklyn, 
offers  a  series  of  three-months'  courses  for  both  men  and  women, 
which  are  to  cover  the  following  topics:  (1)  The  selection  of  food 
material  as  to  quality,  food  value,  and  cost.  Marketing  and  buying 
by  sample.  (2)  Methods  of  preparation  in  a  large  way  and  by  ap- 
propriate apparatus.  (3)  The  care  of  food,  cold  storage,  etc.  (4) 
Serving,  embodying  general  dining  economy,  labor-saving  appliances, 
etc.  (5)  Field  work:  visits  to  public  kitchens,  and  manufactories 
of  kitchens,  and  hotel  furnishings. 


PART  VIII 
DIET  IN  DISEASE  — DIET  IN  INFECTIOUS  DISEASES 


DIET  IN  FEVER  IN  GENERAL 

THE  general  principles  of  the  dietetic  treatment  of  the  condition 
of  fever  which  accompanies  many  different  diseases  are  conveniently 
studied  collectively,  while  the  special  modifications  of  diet  required 
for  certain  infectious  fevers  will  be  considered  under  their  several 
headings. 

The  cardinal  principles  of  feeding  the  sick  involve,  first,  the  avoid- 
ance of  all  articles  that  disagree  with  the  conditions  present,  and 
second,  the  giving  of  the  food  best  adapted  to  relieve  the  digestive 
organs  of  unnecessary  labor  and  to  maintain  nutrition.  In  addition, 
for  certain  special  diseases  there  are  classes  of  foods  which  have 
distinctly  curative  value  —  for  example,  the  use  of  fresh  fruits  and 
vegetables  in  scurvy,  fats  and  oils  in  septicaemia  and  tuberculosis. 
Although  there  is  no  curative  food  for  fevers,  it  should  be  remem- 
bered that  there  is  nothing  so  easily  assimilated  as  water,  and  ad- 
vantage may  be  taken  of  this  fact  to  introduce  other  foods  into  the 
body  with  it,  giving  them  therefore  in  fluid  form. 

Pathological  Physiology  of  Fever. —  The  former  treatment  of 
fevers  by  starvation  and  depletion,  on  the  theory  that  the  poison 
of  the  disease  was  soonest  conquered  by  withholding  all  food  and 
drink  upon  which  it  might  thrive,  and  starving  out  "a  devouring 
flame  of  inflammation,"  has  long  been  superseded  by  scientific 
methods.  This  early  treatment  culminated  in  France  in  the  first 
part  of  the  last  century,  and  was  first  combatted  in  England  by  Graves, 
who  "  fed  fevers,"  and  his  successful  followers. 

It  is  now  known  that  in  fevers  by  supplying  the  patient  with  abund- 
ant food  the  tissues  of  the  body  are  spared  from  consumption  —  in 
other  words,  that  the  food  is  burned  up  or  oxidized  instead  of  the 
proteid  matter  of  the  patient's  muscles  and  other  structures.  The 
food  thus  given  does  not  usually  add  to  the  substance  of  the  tissues, 
but  saves  them  from  wasting  and  combustion.  For  this  purpose  both 
carbohydrates  in  the  form  of  gruels,  and  especially  milk  sugar,  and 
simple  proteids  are  best.  (See  Coleman's  experiments  in  feeding 
typhoid  fever  patients,  p.  478.) 

463 


464  DIET   IN   DISEASE 

Bauer  believes  that  "  the  gravest  possible  injury  to  the  organism 
of  the  fever  patient  may  be  brought  about  by  a  diet  too  rich  in  albu- 
minates," and  to  some  extent  carbohydrates  and  gelatin  may  be 
substituted  for  them,  yet  he  adds  that  while  "  an  exclusive  use  of 
albuminates  is  undesirable  ...  in  fever  a  larger  relative  pro- 
portion of  albuminates  is  requisite  than  in  health,  and  so  much  larger 
as  the  albuminous  metabolism  is  greater." 

Fever  patients  commonly  excrete  more  nitrogen  than  they  take  in 
as  food.  In  so  doing  it  is  believed  that  they  first  exhaust  whatever 
reserve  supply  may  be  on  hand  in  the  food  proteids  previously  ab- 
sorbed and  circulating  in  the  blood,  and  subsequently  draw  upon  the 
tissues,  just  as  is  the  case  in  starvation.  The  urea  daily  eliminated 
during  fever  may  exceed  by  an  ounce  or  an  ounce  and  a  half  the 
normal  amount  voided  in  the  urine  during  health,  and  this  may  be 
the  case  even  when  no  food  is  given;  hence  the  waste  increase  is 
mainly  nitrogenous.  In  chronic  fevers  with  remissions,  like  tuber- 
culosis, there  is  less  rapid  waste  than  in  the  continuous  forms  such 
as  typhoid.  If  the  digestion  remains  fairly  good  in  any  fever,  the 
loss  of  body  weight  is  proportionately  checked. 

Voit  suggested  the  theory  that  the  tissues  act  somewhat  after  the 
manner  of  gland  cells,  and  normally  attract  such  proteid  sub- 
stances as  they  need  without  themselves  undergoing  any  serious 
change,  and  Bauer  believes  that  this  hypothesis  may  be  applied  to 
the  consumption  of  proteids  in  fever,  "that  under  those  conditions 
which  the  febrile  processes  bring  with  them  the  tissues  yield  up  to 
the  circulation  a  large  proportion  of  their  own  albumin,  and  that 
an  abnormal  amount  of  materials  for  metabolism  is  thus  presented 
to  the  cells."  The  organs  meanwhile  lose  proteids  faster  than  in 
ordinary  starvation,  but  by  similar  processes.  A  single  proteid  meal 
adds  protein  to  the  circulation,  which  in  starvation  would  aid  in  re- 
storing equilibrium;  but  in  fever  it  fails  to  do  so,  and  the  loss  con- 
tinues because  the  tissue  cells  have  for  the  time  being  lost  their 
power  of  assimilation.  Emaciation  therefore  proceeds. 

Another  theory  which  has  been  strongly  advocated,  but  which,  on 
the  whole,  has  less  to  recommend  it,  is  that  the  tissues  consume  and 
destroy  proteid  material  from  the  blood  at  a  much  faster  rate  than 
in  health,  and  supplying  a  purely  proteid  diet  does  not  check  the 
waste.  The  entire  question  is  exceedingly  intricate  and  difficult  of 
solution.  The  experiments  which  have  been  made  in  febrile  metab- 
olism are  somewhat  contradictory,  and  it  is  undoubtedly  better  to 
be  guided  at  present  by  the  results  of  clinical  experience  in  feeding 
fever  patients  than  by  theoretical  formulae. 


DIET   IN   FEVER  IN   GENERAL  465 

This  subject  is  physiologically  very  closely  related  to  the  paren- 
chymatous  and  fatty  degenerations  of  organs  which  attend  many 
diseases,  but  it  is  impossible  within  the  practical  limitations  of  this 
work  to  enter  into  this  discussion,  and  the  reader  is  referred  to  a 
very  able  presentation  of  these  theories  in  the  chapter  upon  Con- 
sumption in  Febrile  Disease  by  Bauer  in  his  Dietary  of  the  Sick 
(Handbook  of  General  Therapeutics,  v.  Ziemssen). 

Leyden  and  Frankel  believe  that  in  fever  more  fat  as  well  as 
more  albumin  is  consumed  than  in  health,  but  other  authorities 
think  that  fat  katabolism  does  not  keep  pace  with  proteid  katabolism. 

In  fever  the  secretion  of  hydrochloric  acid  is  diminished  or  sus- 
pended in  the  stomach,  and  its  peristaltic  action  is  so  lessened  that 
the  food  is  liable  to  remain  longer  than  it  should  and  undergo-  mal- 
fermentation,  causing  oppression  or  pain,  nausea,  and  vomiting. 
Absorption  also  is  reduced  in  fevers.  The  stomach  may  completely 
give  out,  and,  as  Eoberts  observes,  it  becomes  merely  a  conduit,  so  that 
the  intestine  must  carry  out  the  work  of  digestion  unaided. 

Dietetic  Treatment. —  The  conditions  to  be  met  in  the  dietetic 
treatment  of  fevers  are  as  follows: 

1.  To  save  tissue  waste  by  supplying  sufficient  nourishment. 

2.  To  give  semisolid  or  fluid  nourishment  in  a  form  which  will 
not  overtax  the  enfeebled  digestive  apparatus  or  leave  a  large  residue 
for  decomposition. 

3.  To  give  abundant  fluid  with  the  object  of  relieving  thirst  and 
to  wash  out  through  the  kidneys  the  waste  matter  produced  by  the 
increased  rate  of  katabolism. 

In  all  fevers  presenting  periods  of  remission  it  is  desirable  to 
supply  the  greater  portion  of  the  food  while  the  temperature  is  lowest, 
so  that  it  will  be  digested  and  absorbed  better,  for  at  this  time  the 
tissues  appear  to  recover  temporarily  their  assimilative  power  to  some 
extent. 

In  mild  cases,  with  remissions,  if  the  appetite  holds  out,  it  may 
do  no  harm  to  allow  some  little  variety  in  the  diet;  but  if  the  fever 
be  brief  and  the  appetite  fails,  it  is  unnecessary  to  force  the  patient 
to  take  food. 

As  a  rule,  in  fevers  which  are  protracted  or  severe,  nourishment 
should  be  given  in  fluid  form  at  2  or  3  hour  intervals.  To  offer 
solid  food  in  serious  fevers  is  practically  to  place  foreign  bodies  in 
the  alimentary  canal  which  merely  ferment  and  putrefy,  causing  dis- 
comfort with  flatus,  fetor,  and  diarrhoea.  There  are  some  exceptions 
to  this,  notably  the  fever  of  phthisis,  some  forms  of  protracted  sepsis, 
and  acme. 


466  DIET   IN   DISEASE 

Milk  being  the  first  and  "  natural  food  "  of  man,  it  would  seem 
most  appropriate  that  it  should  constitute  the  staple  article  of  diet 
in  fevers  in  which  the  digestive  powers  are  temporarily  greatly  en- 
feebled or  wholly  suspended.  The  danger  from  its  continuous  and 
exclusive  use  arises  from  its  coagulating  in  lumpy  masses,  which  act 
practically  as  solid  food,  but  the  many  means  which  are  at  the  dis- 
posal of  the  physician  and  nurse  make  it  possible  to  overcome  this 
difficulty  almost  completely,  and  by  processes  of  artificial  digestion 
milk  may  be  given  ready  for  absorption,  so  that  nutrition  is  rendered 
quite  independent  of  stomach  and  intestinal  digestion.  In  the  ma- 
jority of  cases,  therefore,  milk  is  altogether  the  best  food  as  a  basis. 
The  methods  of  giving  it  are  described  in  the  section  upon  Adapta- 
tion of  Milk  for  the  Sick  (p.  84),  and  upon  the  Treatment  of  Typhoid 
Fever  (p.  474). 

Next  in  importance  to  milk  in  the  diet  of  fever  are  to  be  men- 
tioned the  various  preparations  of  meat  —  infusions,  extracts,  ex- 
pressed juice,  powder,  broths,  etc.  (p.  135).  These  preparations  may 
be  made  from  tender  veal,  chicken,  roast  beef,  and  beefsteak.  Clear 
soups  or  consommes  are  nutritious  and  mildly  stimulating  in  fevers, 
but  if  given  often  or  in  large  quantities  patients  usually  tire  of  them, 
and  they  may  be  considerably  varied  by  flavoring  with  vegetable 
juices  and  extracts  or  aromatic  herbs,  which  afford  variety,  and  as  a 
rule  do  no  harm,  unless  exhausting  diarrhoaa  be  present. 

Purees  may  be  given,  made  by  thickening  clear  soup  with  well- 
cooked  arrowroot,  or  finely  ground  rice,  or  thoroughly  baked  wheaten 
flour.  Bauer  recommends  the  use  of  "  fruit  soups,"  which  are  pre- 
pared by  boiling  fruit,  either  fresh  or  dried,  with  the  addition,  if 
desired,  of  grape  sugar,  lemon  peel,  etc.  The  mass  is  then  compressed 
and  strained,  and  the  fluid  obtained  has  an  agreeable  taste  and  some- 
what laxative  action. 

In  cases  of  moderate  severity  and  short  duration,  when  the  di- 
gestive organs  are  not  greatly  disturbed,  it  is  not  necessary  to 
confine  the  patient  to  fluids,  although  solid  food,  especially  meats, 
should  be  withheld.  Semisolid  food  may  be  given,  such  as  milk 
toast,  cream  toast,  soft-cooked  eggs,  beef  jelly,  or  plain  rice  pud- 
ding. Thoroughly  boiled  oatmeal  gruel  sustains  strength  while  un- 
dergoing severe  physical  toil,  and  fever  has  some  resemblance  to 
muscular  effort  in  its  temporary  arrest  of  digestive  activity,  so  that 
sometimes  substances  of  this  class  prove  useful  from  their  supporting 
power. 

Many  other  varieties  of  farinaceous  and  other  carbohydrate  foods 
are  suitable  in  febrile  cases  when  carefully  prepared  in  fluid  form. 


DIET   IN  FEVER   IN   GENERAL  467 

Patients  often  object  to  these  substances  for  the  reason  that  they 
are  tasteless  and  monotonous,  whereas  if  prepared  with  a  little  care, 
by  giving  proper  attention  to  their  flavoring,  they  may  be  made 
very  palatable.  Thin  gruels  of  rice,  oatmeal,  or  barley,  from  which 
all  solid  matter  has  been  removed  very  carefully  by  straining  through 
a  cheese-cloth  bag,  may  be  salted  and  flavored  with  any  desirable 
aromatic,  such  as  cinnamon,  clove,  nutmeg,  lemon  or  orange  peel; 
grape  sugar  also  may  be  added.  Such  gruels  may  be  prescribed 
either  alone  or  combined  with  meat  extracts,  or  beef  tea,  or  beaten 
eggs.  The  addition  of  grape  sugar  has  been  recommended  by  See 
and  others  because  of  its  ready  absorption,  and  from  the  fact  that 
it  is  the  form  of  sugar  which  is  produced  from  the  digestive  fermen- 
tation of  starches,  and  is  to  be  regarded,  therefore,  as  an  easily 
assimilable  carbohydrate  which,  to  a  great  extent,  may  prevent  tissue 
waste  by  furnishing  fuel  to  the  body. 

If  a  patient  be  fed  upon  clear  farinaceous  gruels  alone  during 
fever,  he  cannot  thus  obtain  over  eight  or  ten  grams  of  protein 
per  diem,  or  one-twelfth  of  the  quantity  required  by  a  healthy  man 
at  rest,  and  obviously  he  will  suffer  within  two  or  three  days  from 
tissue  waste  and  inanition.  Egg  albumen,  or  meat  broths,  should 
therefore  be  added. 

Eggs  may  be  eaten,  but  they  should  never  be  hard  boiled,  and  in 
fact  they  require  little  cooking.  They  may  be  beaten  with  boiling 
water  and  strained  and  dropped  into  consomme  or  light  broth  or 
gruel.  The  yolk  and  the  white  may  be  used  either  separately  or  to- 
gether. The  yolk  may  be  beaten  with  hot  milk  and  water,  or  with 
hot  tea  sweetened  with  grape  sugar  (Yeo),  or  it  may  be  added  to 
brandy.  The  brandy  mixture  of  the  British  Pharmacopoeia  (Mistura 
spiritus  vini  gallici,  Br.  Ph.)  is  made  as  follows:  The  yolks  of  two 
eggs  with  half  an  ounce  of  refined  sugar  are  beaten  and  added  t<> 
four  ounces  of  Cognac  and  an  equal  amount  of  cinnamon  water. 
The  brandy  in  this  mixture  may  be  diluted  still  further  or  reduced 
to  advantage.  Some  patients  prefer  to  take  eggs  raw,  while  others 
prefer  to  have  them  very  slightly  cooked  by  immersing  them  in 
water  which  has  been  boiling,  thus  cooking  them  very  slowly  at  a 
temperature  not  exceeding  180°  F.  for  ten  or  fifteen  minutes.  Eggs 
prepared  in  this  way  are  uniformly  and  lightly  cooked,  and  the  al- 
bumin is  coagulated  in  a  soft  gelatinous  mass  instead  of  the  hard, 
white,  tough  coagnlum  which  is  produced  by  greater  heat  (see  p.  123). 

Cold  meat  jellies  as  well  as  simple  sherry  wine  and  lemon  jellies 
occasionally  may  be  given,  but  gelatin  alone  is  not  particularly  nu- 
tritious, and,  in  proportion  to  the  bulk  occupied  by  this  class  of 


468  DIET   IN   DISEASE 

foods,  comparatively  little  benefit  is  derived  from  them,  except  as 
"tissue  sparers"  (see  p.  146). 

Gelatin  given  with  other  foods,  especially  those  of  proteid  com- 
position, is  assimilated  much  better,  and  makes  a  desirable  addition 
to  the  dietary  in  mild  cases.  When  added  to  milk  in  the  form  of 
blancmange  patients  usually  enjoy  it. 

Beef  tea  and  chicken  jelly  in  equal  parts  make  an  excellent  com- 
bination. 

Orange  juice  and  pineapple  juice  may  be  given. 

SUMMARY  OF  FOODS  FOR  FEVERS. —  Beef  juice,  beef  tea,  beef  ex- 
tracts, solid  or  fluid  (p.  135),  peptonoids.  mutton,  chicken  or  veal 
broth,  meat  soups  flavored  with  vegetable  extracts,  celery  salt,  etc., 
bouillon,  consomme. 

Eggs,  raw  or  soft  cooked,  dropped  into  bouillon  or  soups,  beaten 
with  milk.  White  of  egg  in  sherry  or  milk.  Eggnog,  milk,  plain, 
peptonized,  diluted  with  water,  lime  water,  Vichy  or  carbonic  water. 

Buttermilk,  milk  punch,  koumiss,  junket.  Cream  diluted  with 
one-fourth  to  one-half  Vichy.  Milk  sugar  —  one  or  two  teaspoonf uls 
in  water  or  added  to  milk  or  other  foods. 

Gruels  of  rice,  farina,  cornstarch,  arrowroot,  banana  meal. 

Gelatine  foods,  as  chicken  or  beef  jelly,  blancmange,  arrowroot, 
sherry  or  port  wine,  lemon,  or  coffee  jellies. 

Fruit  juices,  oranges,  pineapple.     (See  Eeceipts  for  Invalid  Diet.) 

Beverages  in  Fevers 

The  Value  of  Water  and  Other  Beverages. —  In  almost  all  febrile 
affections  the  liberal  use  of  water,  or  some  beverage  composed  chiefly 
of  water,  is  to  be  recommended  both  for  the  relief  of  thirst  and  on 
account  of  its  diluent  effect  and  of  its  increasing  the  facility  with 
which  the  waste  matter  resulting  from  the  rapid  metabolism  of  the 
fever  is  eliminated  through  the  kidneys.  A  dry  mouth  destroys  ap- 
petite. (See  care  of  the  Mouth,  p.  482.)  The  toxins  produced  by 
the  action  of  typhoid-fever  germs  and  other  microorganisms  are 
diluted  and  are  in  some  degree  "  washed  out "  of  the  system  by  the 
imbibition  of  large  draughts  of  water.  Patients  who  are  extremely 
feeble,  or  who  are  not  wholly  rational,  may  not  ask  for  drink  al- 
though their  mouths  are  dry  and  parched,  and  it  should  always  be 
the  duty  of  the  nurse  to  give  water  in  proper  quantity  at  regular 
intervals.  In  long-continued  fevers  there  is  a  tendency  for  an  in- 
creased loss  of  water  from  the  surface  of  the  lungs,  and  sometimes 
from  the  skin,  although  the  kidneys  may  be  less  active  than  normal, 
and  if  care  be  not  taken  to  replace  the  fluid  in  the  body  the  effects 


DIET   IN   FEVER  IN   GENERAL  469 

of  this  loss  become  much  more  pronounced.  If  there  are  profuse 
watery  evacuations  from  the  bowels  the  drain  of  fluid  from  the  blood, 
and  eventually  from  other  body  tissues,  is  considerable. 

Sour  lemonade  constitutes  one  of  the  most  useful  and  refreshing 
of  beverages.  It  is  not  likely  to  disorder  the  stomach,  especially  if 
taken  in  the  intervals  between  the  ingestion  of  food,  and  to  many 
persons  it  is  very  acceptable.  It  may  be  made  effervescing  by  the 
addition  of  Vichy,  carbonic-acid  water,  soda  water,  or  ten  grains  of 
sodium  bicarbonate.  Orangeade  may  be  made  with  Vichy. 

Barley  and  rice  water  with  a  little  lemon  juice  and  sugar,  or  with 
cinnamon,  wine,  and  sugar,  afford  refreshing  drinks  to  many  per- 
sons, especially  children,  but  they  contain  very  little  nourishment. 
Either  tea  or  coffee  may  be  allowed  once  a  day  in  many  cases  of 
fever,  although  this  fact  is  often  overlooked.  Tea  should  be  avoided 
if  there  is  marked  indigestion  in  the  stomach,  and  coffee  as  well  as 
tea  should  be  avoided  in  cases  where  there  is  insomnia  or  excessive 
nervousness.  If  there  is  flatulency  they  should  be  given  without 
sugar,  and  not  with  other  food.  Persons  who  object  to  the  taste 
of  milk  may  take  it  if  a  tablespoonful  of  good  coffee  be  added  to 
the  tumblerful.  Strong  black  coffee,  moreover,  is  useful  in  con- 
trolling vomiting,  and  is  mildly  stimulating  in  cases  of  heart  failure. 
Its  diuretic  action  is  also  serviceable  in  fever,  but  it  should  be  recol- 
lected that  those  who  are  not  ordinarily  disagreeably  affected  by  the 
daily  use  of  strong  coffee  may  be  made  very  nervous  by  small  quan- 
tities given  when  the  system  is  reduced  by  the  wasting  processes  of 
fever.  Both  tea  and  coffee  should  be  used,  therefore,  with  discre- 
tion. Other  useful  beverages  are  whey,  or  whey  and  beef  tea,  either 
hot  or  iced,  and  unfermented  grape  juice. 

For  the  immediate  relief  of  thirst  cracked  ice  may  be  given,  but 
it  sometimes  parches  the  lips. 

The  question  of  the  temperature  at  which  milk  or  any  form  of 
beverage  should  be  given  in  fevers  may  safely  be  left,  in  most  cases, 
to  the  liking  of  the  patient.  I  have  elsewhere  shown  (p.  375)  that 
the  body  temperature  can  be  little  if  any  affected  by  that  of  ingested 
fluids,  and  it  is  of  more  importance  to  give  them  in  so  agreeable  a 
form  that  they  will  not  be  refused.  An  excess  of  cold  drinks  may 
embarrass  digestion  or  cause  stomach  cramps,  and  should  be  avoided, 
but  any  cold  fluid  slowly  sipped  will  do  no  harm. 

SUMMARY  OF  BEVERAGES  FOR  FEVERS 

Water,  barley,  rice,  or  oatmeal  water,  weak  tea  or  coffee,  cocoa,  lem- 
onade, orangeade,  effervescing  waters,  as  Appollinaris,  Vichy,  or  car- 


470  DIET   IN   DISEASE 

bonic  water,  flaxseed  tea,  cream-of -tartar  drink,  whey  posset.     (See 
Receipts  for  Invalid  Diet.) 

Alcohol  in  Fevers 

The  principal  theory  of  the  action  of  alcohol  in  fevers  is  that  it 
serves  as  a  readily  absorbable  food;  and  it  is  believed  that  its  com- 
bustion saves  in  some  degree  the  wear  and  tear  of  the  tissues,  as  the 
alcohol  burning  in  a  spirit  lamp  furnishes  energy  in  the  form  of  heat, 
and  itself  becomes  burned  to  waste  products,  but  spares  the  carbon  of 
the  wick.  The  latter  is  not  itself  burned  up  or  oxidized  until  the  al- 
cohol has  been  exhausted.  Another  theory  of  the  use  of  alcohol  is  that 
it  possesses  a  positive  antipyretic  action  by  which  it  controls  the  body 
temperature  by  restricting  heat  production.  It  is  also  believed  that 
alcohol  in  fever  acts  upon  the  nervous  system,  strengthening  and  sup- 
porting it,  in  this  manner  indirectly  controlling  the  nerve  currents 
which  preside  over  the  activity  of  nutrition,  chemical  change,  and 
heat  production.  The  subject  is  a  broad  one,  and  obscured  by  lack 
of  definite  knowledge  of  the  chemical  processes  concerned  in  heat 
production.  It  is  possible  that  alcohol  may  act  simultaneously  in 
all  the  ways  suggested,  having  the  combined  effect  of  a  food,  a  nerve 
tonic,  and  an  antipyretic.  This  view  has  been  advocated  ably  by 
Dujardin-Beaumetz,  who  gives  an  exhaustive  discussion  on  the  sub- 
ject in  his  work  on  alimentation  in  fevers  (Du  Regime  Alimentaire 
dans  les  Maladies  Febriles,  p.  227). 

Light  white  wines,  diluted  claret,  and  beer  are  recommended  in 
fevers  by  many  foreign  writers  on  dietetics,  especially  in  those  coun- 
tries in  which  good  water  is  unobtainable,  or  in  which  for  other 
reasons  wine  drinking  is  in  more  common  daily  use  than  it  is  in 
America,  where  there  is  an  abundant  supply  of  pure  water.  In 
France  and  Germany  light  red  wine  is  customarily  allowed  through- 
out the  course  of  mild  fevers,  and  from  five  to  ten  ounces  are  given 
daily.  The  fever  diet  in  the  Munich  General  Hospital  includes  150 
to  300  grams  (5-10.  ozs)  of  light  red  wine  or  white  wine.  Beer  is 
much  used  in  Germany  for  fevers,  and  contains  some  nourishment. 

In  this  country  alcohol  is  not  much  relied  upon  as  a  food  in 
fevers  and  its  use  as  a  stimulant  also  is  at  present  very  much  less 
than  one  or  two  decades  ago.  In  a  large  general  medical  hospital 
service  I  have  known  many  of  the  gravest  cases  do  perfectly  well 
without  it. 

If  alcohol  is  not  required  for  its  stimulating  effect  upon  the  cir- 
culatory or  nervous  systems  it  is  better  to  withhold  it,  for  in 
continued  fevers  emergencies  may  at  any  time  arise  in  which  it  is 


DIET   IN   FEVER   IN   GENERAL  471 

imperatively  demanded  to  strengthen  the  failing  powers  or  aid  in  con- 
trolling the  exhaustion  of  delirium.  Its  influence  will  always  be 
more  decided  and  its  action  can  be  much  better  controlled  if  spirits 
have  not  been  given  previously,  and  when  it  is  needed  for  any  such 
reason  it  is  best  to  prescribe  it  in  the  form  of  brandy  or  whisky,  or 
champagne,  if  vomiting  be  present.  The  "  typhoid  condition  "  super- 
vening in  the  course  of  any  fever  often  demands  it  —  i.  e.,  the 
condition  characterized  by  great  prostration,  low  muttering  delirium, 
subsultus,  rapid  feeble  pulse,  dry  tongue,  etc. 

In  the  convalescence  following  prolonged  fever  the  daily  use  of 
liquors  with  meals,  or  in  the  form  of  toddy  or  punches  between  meals, 
two  or  three  times  a  day,  is  occasionally  indicated.  This  is  particu- 
larly the  case  among  elderly  people  convalescing  from  pneumonia 
and  other  acute  febrile  diseases  or  who  have  been  greatly  weakened 
by  some  prolonged  adynamic  disease. 

Persons  who  have  been  habitual  though  moderate  drinkers  for 
many  years,  or  throughout  their  lives,  when  attacked  with  any  severe 
acute  or  infectious  disease  possess  less  vitality  and  resistance  than 
those  whose  tissues  have  not  been  bathed  constantly  in  alcohol.  To 
withhold  the  long-accustomed  stimulation  in  these  cases  is  often  to 
precipitate  serious  exhaustion,  and  the  problem  of  properly  adapting 
the  quantity  of  alcohol  to  the  patient's  actual  needs  becomes  a  serious 
one  to  the  physician,  to  which  he  should  give  careful  study.  Caution 
should  be  given  against  the  continued  use  of  alcohol  by  patients  in 
whom  there  is  danger  of  inducing  the  alcohol  habit.  It  not  infre- 
quently happens  that  those  who  have  been  addicted  to  excessive  drink- 
ing, but  who  have  been  cured  temporarily  of  the  habit,  and  who  have 
taken  no  liquor  for  possibly  several  years,  acquire  some  acute  disease 
in  which  there  is  need  of  active  alcoholic  stimulation.  In  such  cases, 
having  in  view  the  possible  recovery  of  the  patient,  with  a  renewal  of 
his  alcohol  habit,  this  stimulant  should  be  withheld  as  long  as 
possible  while  efforts  are  made  to  sustain  the  enfeebled  heart  power 
by  strychnine,  digitalis,  or  diffusible  cardiac  stimulants,  such  as  ether, 
ammonium  carbonate,  aromatic  spirit  of  ammonia,  camphor,  etc. 

From  the  above  account  it  appears  that  the  question  of  the  use 
of  alcohol  in  febrile  disorders  should  be  considered  from  two  stand- 
points, embracing,  first,  its  value  as  a  food,  with  its  relation  to  other 
foods  and  to  nutrition;  second,  its  value  as  a  stimulant  and  the  ex- 
tent to  which  it  may  be  replaced  or  re-enforced  by  drugs.  The  con- 
tinued use  of  strong  alcohol  always  disorders  digestion,  and  since 
the  stomach  is  weakened  in  fevers,  it  is  more  susceptible  to  such  in- 
fluences, and  this  is  an  additional  argument  for  not  employing  al- 


472  DIET   IN   DISEASE 

cohol  in  a  routine  method,  but  for  saving  it  for  positive  indications, 
such  as  asthenia. 

Diet  in  Convalescence  from  Fevers 

Convalescents  who  have  long  subsisted  solely  upon  fluids  should  be 
careful  in  resuming  solid  diet,  for  the  rapidity  of  recuperation  of 
the  digestive  organs  varies  in  different  persons,  and  taking  meats  or 
other  solid  foods  too  soon  may  cause  rise  in  temperature,  quickened 
heart  action,  and  possibly  visceral  congestion.  The  first  meat  given, 
therefore,  should  be  in  a  finely  subdivided  state,  such  as  scraped  beef 
or  minced  chicken. 

During  convalescence  from  protracted  fevers  the  more  easily  di- 
gested forms  of  amylaceous  foods  are  found  to  be  very  acceptable,  es- 
pecially if  there  has  been  much  loss  of  weight.  Sago  and  tapioca 
thoroughly  cooked  and  served  with  cream  are  highly  nutritious,  and 
dried  bread  crumbs  rolled  through  a  fine  sieve  may  be  added  to  thicken 
clear  meat  broths.  Crackers  and  zwieback  are  useful. 

Other  ingredients  which  may  be  added  to  thicken  soups  during 
convalescence  are  panada,  semolina,  tapioca,  spaghetti  and  macaroni. 
Custard  puddings,  cooked  fruits,  wine  and  beef  jellies,  blancmange,  or 
baked  custard  may  be  allowed.  Cornmeal  "  mush,"  fine  hominy,  corn- 
starch,  farina,  and  boiled  rice,  with  beef  juice,  may  be  ordered. 

The  following  dietary  will  serve  as  a  general  guide  for  feeding 
convalescents  from  fevers  of  ordinary  severity  in  which  special  lesions 
of  the  alimentary  canal  are  not  present.  It  is  taken  from  a  Hand- 
book of  Invalid  Cooking: 

FIRST  DAY 

Breakfast. —  Poached    egg   on   toast.     Cocoa. 

Lunch. —  Milk  punch. 

Dinner. —  Raw  oysters.     Cream  crackers.     Light  wine  if  desired. 

Lunch. —  One  cup  of  hot  beef  broth. 

Supper. —  Milk   toast.     Wine   jelly.     Tea. 

SECOND  DAY 

Breakfast. —  Soft-cooked  egg.     Milk  punch.     Coffee  with  sugar  and  cream. 
Lunch. —  One  cup  of  soft  custard. 

Dinner. —  Cream-of-celery  soup.     Sippets  of  toast.     A  little  barley  pudding, 
with  cream.     Sherry  wine  if  desired. 
Lunch. —  Milk  punch. 
Supper. —  Water  toast,  buttered.     Wine  jelly.     Tea. 

THIRD  DAY 

Breakfast . —  Scrambled    egg.     Cream    toast.     Cocoa. 
Lunch. —  One  cup  of  hot  chicken  broth. 

Dinner. —  Chicken  panada.  Bread.  Light  wine  if  desired.  A  little  tap- 
ioca cream. 

Lunch . —  An   eggnog. 

tiuppcr. —  Buttered    dry   toast.     Baked    sweet   apples   and    cream.     Tea, 


J)IET   IN   FEVER  IN   GENERAL  473 

FOURTH  DAY 

Breakfast. —  An  orange.  Oatmeal  ("H-O"),  with  cream  and  sugar. 
Poached  egg  on  toast.  Baked  potato.  Cocoa. 

Lunch. —  One  cup  of  hot  soft  custard. 

Dinner. —  Potato  soup.  Croutons.  A  small  piece  of  beefsteak.  Creamed 
potatoes.  Baked  custard.  Coffee. 

Lunch. —  One  cup  of  chicken  broth,  with  rice. 

Supper. —  Raw  oysters.  Banquet  crackers.  Graham  bread,  toasted.  Wine 
jelly.  Tea. 

FIFTH  DAY 

Breakfast. —  An  orange.  Coffee.  Oatmeal,  with  cream  and  sugar.  Broiled 
mutton  crop.  Toast. 

Lunch. — One  cup  of  mulled  wine. 

Dinner. —  Chicken  soup.  Bread.  Creamed  sweetbreads.  Duchess  potato. 
Snow  pudding.  Cocoa. 

Lunch. —  Siphon  soda,  with  coffee  sirup  and  cream. 

Supper. —  Buttered  dry  toast.  Orange  jelly.  Sponge  cake  and  cream. 
Tea. 

(See  Diet  in  Convalescence  from  Typhoid  Fever,  p.  483,  which 
may  be  taken  as  a  standard  for  other  fevers.) 

DIET  IN  INFECTIOUS  DISEASES 

TYPHOID  FEVER 

Careful  nursing  and  diet  regulation  are  the  life-saving  agents  in 
typhoid  fever.  In  few  diseases  does  a  closer  relation  exist  between 
right  feeding  and  symptoms. 

Pathological  Physiology. —  In  average  cases  the  fever  lasts  a  month, 
no  matter  what  the  treatment,  whether  by  cold  bathing  or  otherwise, 
while  in  some  it  continues  for  five,  six,  or  more  weeks,  and  the 
disease  may  be  prolonged  further  by  relapses.  There  is  a  convales- 
cent period  of  at  least  two  weeks,  and  often  as  many  months,  dur- 
ing all  which  time  constant  care  in  feeding  must  be  exercised.  At 
any  time  during  the  prevalence  of  the  fever  departure  from  the 
strict  rules  for  diet  laid  down  by  the  physician  may  determine  a 
fatal  issue,  but  it  is  during  the  period  of  ulceration  that  the  greatest 
danger  is  met. 

The  ulcers  involve  the  Peyer's  patches  and  solitary  follicles  in 
the  lower  end  of  the  ileum,  but  they  may  extend  into  the  jejunum, 
and  even  into  the  large  intestine.  They  are  deep  and  clean-cut,  often 
including  the  whole  thickness  of  the  muscular  layers,  sometimes  per- 
forating through  the  serous  layer.  An  overloaded  intestine  or  a 
distended  bowel  may  precipitate  perforation  at  any  moment.  It  is 
therefore  important  to  select  a  diet  which  will  leave  small  residue. 
Intestinal  as  well  as  gastric  catarrh  is  often  present,  interfering  with 
both  digestion  and  absorption. 

The  prolonged  fever  is  itself  a  menace  to  life  by  the  secondary 


474  DIET   IN   INFECTIOUS  DISEASES 

changes  which  it  induces  in  the  alimentary  system.  The  digestive 
secretions  are  altered  in  quality  and  lessened  in  quantity.  Enfeebled 
circulation  retards  or  inhibits  absorption,  and  the  functional  activity 
of  the  liver  is  in  abeyance. 

Toxins  in  the  blood,  as  well  as  its  elevated  temperature,  interfere 
with  the  normal  rate  of  metabolism  throughout  the  body,  and  finally 
the  excretory  organs  are  overworked. 

The  typhoid  bacillus  has  curious  behavior  in  relation  to  certain 
food  materials,  e.  g.,  if  cultivated  in  milk  it  prevents  coagulation; 
whey  cultures  become  distinctly  acid,  and  potato  cultures  show  pe- 
culiar modes  of  growth. 

Dietetic  Treatment 

There  are  two  chief  factors  which  should  influence  the  selection 
of  a  proper  diet  for  typhoid  fever:  1.  The  supposed  danger  of 
mechanically  irritating  the  ulcerating  surfaces  in  the  intestine  and 
the  danger  of  overloading  an  intestine  and  stomach  whose  digestive 
functions  are  impaired  by  fever.  2.  The  relations  of  the  chemical 
ingredients  of  the  food  to  the  increased  tissue  change  that  causes  or 
accompanies  the  excessive  production  of  heat.  If  the  proper  fuel  can 
be  furnished  as  food,  the  tissues  are  spared  too  great  self-consumption. 

Milk  Diet. —  In  regard  to  the  first  factor  the  objection  that  parti- 
cles of  solid  food  may  act  as  mechanical  irritants,  erode  a  partially 
or  recently  healed  ulcer,  and  thereby  induce  relapse,  is  hardly  con- 
sistent with  the  modern  view  of  typhoid  fever,  as  a  disease  in  which 
the  germs  are  by  no  means  confined  to  the  alimentary  canal,  but  are 
widely  distributed  throughout  the  body. 

Many  persons  overlook  the  fact  that  undiluted  milk,  on  entering 
the  stomach,  becomes  in  great  part  solid,  and  large-  firm  milk  curds 
are  likely  to  prove  as  irritating  to  the  ulcerating  surfaces,  or  even 
more  so,  than  are  starchy  foods. 

Wlien  patients  are  fond  of  milk  and  digest  and  absorb  it  thor- 
oughly, there  is  no  better  diet  for  typhoid  fever,  and  it  answers 
every  requirement  of  a  fever  food.  It  contains  all  the  essential  ele- 
ments of  nutrition,  is  easily  digested,  furnishes  fluid  to  the  tissues, 
is  a  good  diuretic,  and,  if  properly  administered,  in  many  cases  is 
soothing  to  the  stomach  when  a  mild  degree  of  gastric  catarrh  exists. 
Those  who  dislike  milk  at  first  may  later  grow  accustomed  to  it  and 
take  it  contentedly  for  a  month  or  six  weeks. 

Emphasis,  however,  should  be  given  to  the  fact  that  an  exclusive 
milk  diet  need  not  and  should  not  be  prescribed  in  routine  for  all 
cases.  Within  the  past  few  years  a  number  of  writers  (notably 


TYPHOID  FEVER  475 

Shattuck  of  Boston,  A.  K.  Barrs  of  London,  and  Puritz)  have  advo- 
cated a  departure  from  the  strict  milk  diet  which  had  come  to  be 
the  rule  for  typhoid  fever,  and  it  is  found  beneficial  to  enlarge  the 
dietary  of  some  patients  considerably  by  such  articles  as  strained 
vegetable  soups,  boiled  rice,  macaroni,  soft-cooked  eggs,  meat  juice 
and  broths,  soft  cream  toast,  cream  and  water,  or  Vichy,  buttermilk, 
softened  soda  crackers,  blancmange,  wine  jelly,  milk  sugar,  and  ice 
cream.  It  is  simpler  to  put  all  hospital  cases  of  typhoid  fever  on  a 
routine  milk  diet,  but  it  is  much  better  to  devote  a  little  study  to  se- 
suring  suitable  variation  in  the  food. 

Every  effort  should  be  made  to  maintain  good  stomach  digestion. 
If  all  food  is  thoroughly  disintegrated  before  it  enters  the  intestine 
there  need  be  little  fear  of  a  mechanical  irritation  of  the  ulcerating 
surfaces.  Far  more  danger  may  occur  through  malnutrition  of  the 
intestinal  wall,  which  prevents  absorption  of  nutriment.  An  ac- 
cumulation of  undigested  food  in  the  intestine  is  therefore  highly 
undesirable,  and  the  stools  should  be  examined  periodically  to  see 
that  undigested  milk  eurds  do  not  appear  in  them.  Milk  for  some 
persons  in  health  is  really  a  poison.  They  completely  fail  to  digest 
it.  It  causes  constipation  with  clay-colored  or  white  stools,  and  fills 
the  bowels  with  products  of  malfermentation,  ptomaines,  and  gases. 
They  digest  it  even  less  when  they  acquire  a  prolonged  fever.  Others, 
with  whom  the  milk  agrees,  become  very  tired  of  it  after  taking  it 
exclusively  for  several  weeks.  Several  times  I  have  seen  cases  of 
typhoid  fever  with  symptoms  which  resembled  scurvy,  with  swollen 
and  bleeding  gums  and  great  emacia'tion,  occurring  in  patients  who 
had  been  fed  too  long  upon  an  exclusive  milk  diet  which  they  failed 
to  assimilate. 

Quantity  of  Milk  Required. —  If  milk  is  the  only  food,  enough 
should  be  given,  and  the  problem  of  what  constitutes  enough  must 
be  solved  in  each  case  separately.  Harm  is  done  by  overfeeding, 
which  induces  indigestion  and  restlessness,  increases  the  pulse  rate, 
and  intensifies  the  abdominal  symptoms  —  such  as  tympanites, 
diarrhoea  or  constipation,  hemorrhage,  and  abdominal  pain.  Inges- 
tion  is  very  different  from  digestion. 

There  are  many  writers  upon  dietetics  who  give  a  special  caution 
against  the  practice  of  overfeeding  in  cases  of  typhoid  fever  on  ac- 
count of  the  fact  that  more  or  less  gastric  catarrh  is  usually  present 
and  that  it  is  an  undue  tax  upon  the  digestion  of  the  patient  to 
have  to  deal  with  a  large  bulk  of  food.  On  the  other  hand,  under- 
feeding causes  malnutrition,  favors  the  occurrence  of  complications, 
slow  healing  of  the  ulcers,  and  prolongs  convalescence. 


476  DIET  IN   INFECTIOUS  DISEASES 

For  an  exclusive  milk  diet  the  outside  limits  lie  between  one  and 
three  quarts  per  diem,  depending  somewhat  upon  the  age  and  size 
of  the  individual,  but  more  upon  the  condition  of  his  digestion. 
Three  quarts  furnish  about  100  grams  (3^  ozs.)  of  protein  and  a 
total  energy  of  2,000  calories.  A  clean  tongue,  a  soft  abdomen,  and 
natural  milk  stools,  not  too  hard  and  without  coagulae  of  casein  or 
flakes  of  fat,  indicate  that  the  milk  is  being  well  digested. 

The  reverse  of  these  symptoms  suggests  that  the  milk  is  supplied 
in  too  large  quantity,  or  that  it  is  not  being  digested,  and  one  or  more 
of  three  things  should  be  done:  (a)  The  quantity  may  be  reduced; 
(6)  the  mode  of  administration  may  be  changed  —  i.  e.,  the  milk  must 
be  predigested;  (c)  other  foods  may  be  substituted,  either  wholly  or  in 
part. 

(a)  Quantity. —  When  milk  appears  to  be  well  digested,  but  the 
patient  emaciates  rapidly  early  in  the  disease,  he  is  not  receiving 
nourishment  enough,  and  the  quantity  should  be  increased  or  other 
food  added.  As  a  general  rule,  from  one  and  three-fourths  to  two 
quarts  of  milk  per  diem  (or  six  ounces  every  two  hours,  day  and 
night),  however  diluted,  is  sufficient  during  the  height  of  the  fever  to 
sustain  the  patient  properly.  It  is  best  to  give  as  much  as  can  be 
assimilated  thoroughly  according  to  the  symptoms  above  noted. 

Moore  states  that  very  few  patients  digest  over  one  and  a  half  to 
two  pints  of  milk,  and  "it  is  scarcely  ever  necessary  to  exceed  the 
amount  of  one  quart  of  milk  in  the  twenty-four  hours,"  or  three  ounces 
of  milk  in  ten  feedings  at  intervals  of  two  and  a  half  hours.  This 
estimate,  for  uncomplicated  cases  at  least,  is  too  low.  It  may  be 
necessary  to  reduce  the  allowance  to  this  figure  if  severe  gastroin- 
testinal disturbance  occurs,  or  to  discontinue  temporarily  the  milk 
entirely,  and  give  only  cracked  ice  or  half-ounce  doses  of  iced  cham- 
pagne, but  patients  kept  too  long  on  so  low  a  diet  emaciate,  grow 
feeble  to  an  alarming  degree,  and  require  stimulation. 

(&)  Mode  of  Administration  Changed. —  The  milk  may  be  given 
raw,  boiled,  diluted  with  plain  water,  barley  water,  lime  water,  Vichy, 
Seltzer,  or  Apollinaris,  or  pancreatinized  according  to  taste  and  need. 
Gelatin,  as  well  as  gum  arabic,  is  sometimes  added  to  milk  to  dilute 
it  and  prevent  tough  curds  from  forming.  The  milk  should  never 
be  skimmed.  Its  flavor  may  be  disguised  by  the  addition  of  a  little 
strong  coffee  or  some  of  the  extract  of  coffee,  or  a  little  caramel  makes 
it  agreeable  to  the  taste  where  patients  have  refused  it  before,  or  it 
may  occasionally  he  preferred  with  a  cup  of  cocoa  in  which  the  milk 
predominates.  If  diarrhoea  be  present,  a  milk  diet  is  especially  use- 
ful, and  the  milk  should  he  boiled. 


TYPHOID  FEVER  477 

When  vomiting  occurs  (which  is  unusual),  it  is  better  to  use 
peptonized  or  pancreatinized  milk  than  soda  or  lime  water,  for  the 
latter  tend  to  neutralize  the  activity  of  an  already  enfeebled  gastric 
juice.  These  fluids  may  be  given  either  hot  or  cold,  according  to 
fancy.  If  cold,  the  nausea  is  sometimes  controlled,  but  digestion  may 
be  somewhat  retarded.  If  the  vomiting  is  obstinate,  koumiss,  kefir, 
or  zoolak  may  be  given  for  a  time  with  very  good  result  in  place  of 
milk.  Whey  or  buttermilk  is  also  used  sometimes  for  a  change  for 
a  few  days.  The  late  A.  L.  Loomis  of  New  York  recommended  from 
four  to  six  quarts  of  the  latter  per  diem. 

(c)  Substitutes  for  Milk  Diet. —  When  milk  is  obviously  disagree- 
ing and  producing  flatulence,  I  have  often  seen  improvement  follow 
an  entire  change  of  diet  for  a  day  or  two  to  animal  broths.  Similar 
results  are  familiar  in  the  treatment  of  infantile  diarrhoea. 

In  cases  in  which,  after  fair  trial,  it  is  impossible  to  urge  upon 
the  patient  the  taking  of  milk,  there  is  no  objection  to  giving 
strained  broths  of  mutton,  chicken,  or  beef,  a  little  clam  broth  for  a 
relish,  and  light  farinaceous  articles,  such  as  the  prepared  starchy 
foods,  like  Mellin's  or  Nestle's,  barley  water,  farina,  arrowroot,  and 
other  gruels,  custards,  eggnog,  or  a  piece  of  zwieback  softened  by 
soaking  in  milk,  weak  tea,  or  bouillon.  I  have  used  gruel  made  from 
banana  meal,  which  is  palatable,  highly  nutritious,  and  easily  digested 
(see  p.  218).  Junket  and  cream  are  very  nutritious  and  agreeable 
to  the  palate.  Egg  albumen  may  be  made  very  palatable  by  beating  it 
with  a  little  milk  and  sherry.  In  this  manner  considerable  variety 
is  secured  for  the  patient;  the  appetite,  and  in  many  cases  the  diges- 
tion, are  improved,  and  by  alternating  one  or  more  of  these  articles 
with  the  milk  a  much  larger  quantity  of  nourishment  will  in  the 
end  be  taken  and  absorbed.  Typhoid  patients  may  sometimes  lose  a 
pound  in  weight  per  diem,  and  in  that  class  of  cases  in  which  rapid 
emaciation  is  a  most  alarming  feature  of  the  disease  these  various 
adjuncts  to  the  milk  diet  are  especially  useful.  Patients  fed  in 
this  manner  are  less  likely  to  become  ravenous  during  convalescence. 

It  is  well  expressed  by  Henry  that  "  it  is  not  so  much  solid  as  in- 
digestible food  that  should  be  eschewed,  and  it  should  never  be  for- 
gotten that  all  foods  except  such  as  are  predigested  are  solid  in  the 
first  stage  of  digestion."  A  pint  of  milk  contains  as  much  solid 
material  as  a  mutton  chop. 

The  continued  use  of  beef  tea,  beef  juice,  or  meat  extracts  and 
peptonoids  undoubtedly  produces  loosening  of  the  bowels,  and  such 
substances  should  be  avoided  when  diarrhoea  is  present;  but  in  cases 
where  there  is  a  tendency  to  constipation  this  may  be  a  decided  ad- 


478  DIET  IN   INFECTIOUS   DISEASES 

vantage.  Veal  and  chicken  broth  are  less  likely  to  have  a  laxative  ef- 
fect than  beef  and  mutton  broth,  and  calf's-foot  jelly  is  allowed  by 
some  clinicians.  When  patients  tire  of  the  taste  of  beef  tea  or 
broth  it  may  be  flavored  with  a  little  celery  salt  or,  if  there  is  no 
diarrhoea,  with  a  very  little  tomato  juice  or  other  simple  vegetable 
extract. 

Henry  advocates  the  use  of  gelatin  as  an  "  albumin  sparer,"  al- 
though it  should  not  be  given  if  diarrhoea  is  present.  As  much  as 
a  claret-glassful  may  be  given  on  alternate  days,  and  it  may  be  in 
the  form  of  simple  blancmange  or  peptonized  milk  jelly,  which  is 
made  by  adding,  while  hot,  gelatin  dissolved  in  a  little  water  to  pep- 
tonized or  pancreatinized  milk,  and  flavoring  with  lemon  or  orange 
and  sherry  or  rum.  It  is  eaten  cold.  In  the  stomach  it  is  quite 
as  fluid  as  predigested  milk. 

Farinaceous  Gruels. —  I  have  alluded  to  the  advantage  of  giving 
farinaceous  gruels,  for,  despite  the  fact  that  many  writers  are  op- 
posed to  them  on  the  ground  that  they  may  excite  tympany,  I  be- 
lieve them  to  be  at  times  of  great  service.  Stromeyer  feeds  his 
patients  largely  upon  oaten  grits  boiled  for  three  hours  without  sugar. 

Da  Costa  recommended  giving  three  pints  of  milk  and  one  pint 
of  broth  every  twenty-four  hours,  with  a  midday  allowance  of  some 
gruel,  such  as  arrowroot.  There  is  a  variety  of  enteric  fever  in 
which  without  any  noticeable  complications,  and  even  without  a 
very  high  temperature  curve,  emaciation  is  rapid  and  extreme.  In 
such  cases  especially  the  use  of  farinaceous  gruels  is  indicated.  They 
should  not  be  given  too  sweet,  and  cream  or  lemon  juice  may  be 
added  with  milk  sugar.  It  is  often  advisable  to  add  a  tablespoonful 
of  malt  extract,  or  one  of  the  "prepared  foods/'  such  as  Mellin's, 
Horlick's,  Eidge's,  or  malted  milk  may  be  given  in  milk.  I  have . 
long  used  cream  and  Vichy  in  proportion  of  1  to  4  or  1  to  2  with 
benefit. 

Sugar  has  been  employed  with  benefit  as  a  tissue  sparer  to  pre- 
vent emaciation  in  typhoid  fever.  Klemperer  found  that  the  addition 
of  about  50  grams  of  sugar  and  100  c.  c.  of  cream  to  the  liter  of  milk, 
decidedly  increased  its  nutritive  value.  K.  E.  Ewald  gives  100 
grams  of  milk  sugar  a  day  to  typhoid  patients,  furnishing  410 
calories.  "\Varren  Coleman  and  P.  A.  Shaffer  of  the  Cornell  Uni- 
versity Medical  College  have  recently  conducted  some  valuable  ex- 
periments in  ample  feeding  of  typhoid  patients  with  carbohydrates. 

They  argue  as  follows:  Granted  that  the  minimum  nutrition  re- 
quirement of  a  normal  man  at  rest,  to  prevent  starvation,  is  2.300 
calorics :  in  fever  the  increased  heat  production  averages  20  per  cent 


TYPHOID  FEVER  479 

(Krehl),  which  added  to  the  2,300  calories  makes  more  than  2,700 
calories,  required  to  maintain  nutrition  and  prevent  emaciation  in 
fever.  To  this  Eiibner  would  add  another  10  per  cent  to  make 
good  the  stimulation  of  metabolism  caused  by  food,  hence  about 
3,000  calories  represent  the  daily  requirement  of  the  average  typhoid 
fever  patient.  Carbohydrates  are  better  "  tissue  sparers  "  than  "  heat 
producers/'  and  Coleman  and  Shaffer  found  that  by  supplying  a  maxi- 
mum of  carbohydrate  in  the  form  of  the  easily  assimilable  milk  sugar 
(400-600  grams  per  diem)  not  only  saved  much  loss  of  tissue  nitrogen, 
but  in  some  cases  resulted  in  actual  increase  in  the  patient's  weight. 
Moreover  this  liberal  diet  was  not,  in  their  experience,  attended  by 
any  ill  effects,  beyond  occasional  slight  nausea  and  vomiting,  and 
when  relapses  occurred  (as  they  do  under  any  system  of  treatment) 
the  patients  were  better  fortified  to  bear  them.  Dr.  Coleman  writes 
me: 

"  The  plan  of  feeding  is  to  give  a  diet  as  rich  as  possible  in 
calories  and  to  furnish  as  many  of  the  calories  as  possible  in  the 
form  of  carbohydrates. 

"  The  result  in  sparing  body  protein  is  constant  and  the  amount 
of  sparing  bears  a  direct  relation  to  the  number  of  calories  which 
the  patients  absorb.  In  some  cases  when  they  were  taking  food  repre- 
senting about  4,000  calories,  a  plus  nitrogen  balance  was  obtained 
in  the  urine,  even  when  the  afternoon  temperature  was  rising  to 
103°  F.  A  striking  result  is  the  greater  relative  sparing  action  of 
a  large  excess  of  calories  over  the  supposed  requirement  —  500  calories 
added  to  3,000  cause  the  sparing  of  relatively  much  more  protein 
than  500  added  to  2,000." 

The  maximum  diet  to  be  attained  to  consists  of  milk  iy2  qt., 
cream  1  qt.,  milk  sugar  y2  to  1  lb.,  and  2  to  4  eggs.  The  milk 
sugar  may  be  given:  2  ozs.  in  milk  or  water,  8  ozs.  on  milk  toast,  or 
by  special  receipt.  (See  Eeceipts  for  Invalid  Diet.)  The  cream 
is  given  with  Vichy  or  milk,  milk  toast,  etc.  The  eggs  are 
beaten  in  milk  or  poached  or  soft  cooked.  The  experiments 
have  demonstrated  that  it  is  possible  for  typhoid  fever  patients  to 
assimilate  much  larger  fuel  values  than  they  are  generally  supposed 
to  be  capable  of  doing,  and  to  retain  their  nutrition  meanwhile. 
With  the  accurate  nitrogen  determinations  in  the  urine,  which  con- 
stituted an  important  feature  of  the  experiments,  they  form  another 
argument  in  favor  of  a  liberal  dietary  for  typhoid  fever. 

Sleep  and  Food. —  In  all  cases  of  typhoid  fever  the  question  arises 
in  regard  to  waking  the  patient  at  night  for  nourishment,  or  to  take 
the  temperature.  Some  patients  awaken  easily,  are  fed,  and  drop 


480  DIET  IN   INFECTIOUS   DISEASES 

off  to  sleep  again  almost  immediately.  They  may  be  fed  every  two 
hours  day  and  night.  Others,  if  awakened,  do  not  readily  fall  asleep 
again,  and  lose  half  the  night's  rest  or  more,  and  this  may  con- 
siderably retard  their  recovery.  It  is  sometimes  best  to  let  them 
sleep  for  three  or  four  hours  without  being  aroused,  for  the  rest 
may  be  of  more  benefit  to  them  than  food.  So  much  depends  upon 
the  temperature,  pulse,  and  general  condition  of  each  case  that  no 
rigid  rule  should  be  formulated,  but  it  is  best  never  to  let  more  than 
four  hours  pass  while  the  fever  lasts  without  giving  food.  If  pa- 
tients are  told  that  they  have  a  little  longer  interval  than  usual  in 
which  to  rest  undisturbed,  they  will  sometimes  go  to  sleep  at  once. 
Of  course,  if  they  sleep  during  the  day,  there  is  less  need  of  post- 
poning feeding  by  night.  Constant  drowsiness  may  indicate  a  need 
of  more  food.  The  nurse  should  always  furnish  a  daily  record  of 
the  total  quantity  of  milk  or  broths  given  in  twenty-four  hours 
(making  allowance  for  dilution),  and  this  should  be  compared  with 
the  quantity  of  urine  voided. 

Thirst. —  Thirst  is  a  prominent  symptom  in  typhoid  fever,  and 
cool  water  should  be  given  in  abundance  by  the  nurse,  without  wait- 
ing for  the  patient  to  ask  for  it.  Water  favors  nutrition  and  the 
elimination  of  waste.  If  diarrhoea  be  absent  it  is  well  to  acidulate 
the  water  with  a  little  dilute  phosphoric  or  hydrochloric  acid,  ten  or 
fifteen  drops  to  the  tumblerful,  and  flavored  with  infusion  of  orange 
or  serpentaria.  Hoppe-Seyler  washed  out  the  stomach  in  cases  of 
typhoid  fever,  and  showed  that  while  the  temperature  remains  high 
there  is  little  or  no  acid  contained  in  the  gastric  juice,  and  a  mildly 
acidulated  beverage  may  prove  serviceable  by  aiding  digestion  as  well 
as  by  relieving  thirst.  (For  relief  of  the  latter  symptom,  see  care  of 
the  mouth,  p.  482.) 

The  use  of  cracked  ice  in  excess  augments  thirst  rather  than  relieves 
it,  and  it  is  better  to  sip  cool  water  at  a  temperature  of  50°  to  60° 
F.  rather  than  ice.  The  juice  of  a  sweet  orange  or  a  lemon  is 
acceptable,  and  in  the  absence  of  serious  complications  it  can  do  no 
harm.  AYeak  iced  tea  may  prove  agreeable.  As  a  rule,  it  is  well 
to  restrict  the  use  of  effervescent  drinks  for  the  control  of  thirst 
on  account  of  the  danger  of  increasing  flatulency,  and  stretching  the 
ulcerated  intestinal  wall. 

In  addition  to  the  need  of  water  for  relieving  thirst,  it  is  of  great 
service  as  a  diluent  for  washing  out  the  waste  products  of  febrile 
action  through  the  kidneys.  Many  clinicians  make  it  a  special 
feature  of  their  treatment  to  give  large  draughts  of  water.  Henry 
advises  giving  each  patient  eighty  ounces  of  water  (including  that 


TYPHOID  FEVER  481 

contained  in  fluid  food)  per  diem,  and  Meigs  has  given  as  much  as 
one  hundred  and  thirty  ounces  with  benefit.  Debove  gives  six  ounces 
every  two  hours.  It  should  not  be  drunk  too  soon  after  the  fluid 
food,  but  in  the  intervals,  so  as  not  to  dilute  the  gastric  juice  too 
much.  In  mild  cases  a  little  coffee  or  a  cup  of  cocoa  may  be  drunk 
in  the  morning. 

Alcohol  is  seldom  required  at  all  in  the  first  fortnight.  Later  the 
heart  is  enervated  and  its  muscular  tissue  is  enfeebled.  In  com- 
plications which  threaten  life,  such  as  severe  hemorrhage,  sudden 
cardiac  dilatation,  hyperpyrexia  (106°  F.),  pneumonia,  or  uncon- 
trollable diarrhoea,  alcohol  may  be  required.  When  the  complication 
is  passed  the  dosage  should  be  reduced  gradually.  Twenty-five  years 
ago  I  saw  whisky  prescribed  as  a  routine  practice  at  the  rate  of 
20  or  24  ounces  per  diem.  At  present  I  rarely  use  it  in  typhoid 
fever,  except  in  small  doses,  before  a  cold  bath,  and  usually  prefer 
digitalis  when  a  heart  stimulant  is  needed.  Sometimes  delirium 
will  disappear  when  excessive  dosage  of  alcohol  is  discontinued.  By 
giving  small  doses  of  digitalis  or  strophanthus,  or  the  two  in  com- 
bination, by  the  use  of  caffeine,  camphor,  small  doses  of  morphine, 
and  other  remedies  in  combination  with  alcohol,  much  less  of  the 
latter  will  be  required,  and  there  is  less  danger  of  inducing  the 
alcohol  habit.  Strong  whisky  often  intensifies  the  stomach  catarrh 
and  interferes  with  the  natural  absorption  of  food.  One  very  notice- 
able feature  of  the  Brand  cold-bath  treatment  is  that  the  patients 
do  well  with  so  little  alcohol,  many  of  them  requiring  none  at 
all  in  the  intervals  between  the  baths. 

The  kind  of  alcoholic  stimulant  prescribed  should  depend  upon 
the  circumstances  of  the  case.  Brandy  and  whisky  possess  the  ad- 
vantage that  the  dosage  is  more  uniform  and  the  bulk  is  not  great. 
It  is  a  matter  of  routine  hospital  practice,  founded  largely  on  eco- 
nomic reasons,  to  give  whisky  or  brandy,  but  in  private  practice, 
especially  among  women,  liquors  may  be  distasteful,  and  equally 
good  results  may  be  obtained  by  ordering  some  good  strong  wine 
which  is  more  agreeable  to  the  taste,  such  as  one  of  the  Hungarian 
Avines,  Malaga,  port,  sherry,  claret,  etc.  In  Germany  patients  are 
often  allowed  beer,  but  this  beverage  is  open  to  the  same  objection 
as  the  effervescent  drinks,  for  there  is  more  or  less  gastric  catarrh 
usually  present.  It  is  not  much  prescribed  in  this  country.  It 
serves  better  during  convalescence  than  while  the  fever  is  present. 
Brandy  in  milk  or  soda  or  Seltzer  water  is  best  for  diarrhoea,  and  dry 
champagne  is  good  if  there  is  vomiting.  As  the  latter  is  used  in 
small  doses  —  an  ounce  or  less  at  a  time  —  it  is  economical  to  place 
33 


482  DIET  IN   INFECTIOUS  DISEASES 

a  patent  cork  with  a  faucet  in  the  bottle,  so  that  a  little  may  be 
drawn  at  a  time  without  losing  all  the  effervescence.  In  any  case 
in  which  alcohol  is  given  the  best  guides  for  the  proper  quantity  are 
found  in  the  breath,  delirium,  tongue,  and  pulse.  If  the  breath  has 
no  odor  of  alcohol  an  hour  or  two  after  the  dose  has  been  taken, 
if  delirium  has  subsided,  if  the  tongue  becomes  more  moist,  and  the 
pulse  becomes  more  full  and  slow,  the  alcohol  is  doing  good. 

During  convalescence  a  little  alcohol  —  an  ounce  of  whisky  or 
three  or  four  of  Burgundy  a  day,  for  example  —  may  sometimes  be 
needed  as  a  tonic,  but  should  be  given  only  with  food.  The  malt 
extracts  (p.  189).  are  useful  in  this  stage. 

Relation  of  Intestinal  Antisepsis  to  Diet 

It  is  said  that  bacilli  fed  on  beef  juice  produce  ptomaines  which 
act  more  strongly  upon  the  nervous  system  than  if  they  are  fed 
upon  milk  (Eachford).  The  starches  do  not  make  ptomaines. 

The  typhoid  germs  certainly  thrive  upon  nitrogenous  media,  and 
not  upon  carbohydrates.  Their  development  in  the  former  is  ac- 
companied by  the  production  of  toxic  material  in  the  intestine,  which, 
on  being  absorbed  into  the  system,  produces,  at  least  in  some  part, 
the  symptomatic  phenomena  of  the  disease.  While  there  are  as  yet 
no  remedies  known  to  therapeutics  which  can  be  used  in  sufficient 
strength  in  the  intestine  to  be  completely  antiseptic  or  germicidal 
to  the  typhoid  bacilli,  there  is  the  question  of  asepsis  of  the  ali- 
mentary canal,  which  should  not  be  overlooked  —  that  is,  the  pre- 
vention of  those  fermentative  changes  which  accompany  indigestion 
in  any  fever.  In  typhoid  fever  the  importance  of  maintaining  as 
nearly  as  possible  the  normal  digestion  and  absorption  of  the  food 
is  of  special  urgency  on  account  of  the  long  duration  of  the  disease. 
Moreover,  it  would  appear  that  the  overdistention  of  the  intestine  by 
flatus  must  have  a  very  injurious  effect  upon  the  ulcerating  surfaces 
by  stretching  them.  At  autopsies  upon  typhoid  patients  ulcers  are 
often  seen  which  may  be  torn  easily  by  slight  distention,  and  the 
prognosis  of  typhoid  fever  is  more  grave  whenever  extreme  and  ob- 
stinate intestinal  flatulency  appears. 

Care  of  the  Mouth. —  The  mouth  should  be  washed  frequently  at 
regular  intervals,  and  always  after  taking  a  glass  of  milk,  for  noth- 
ing causes  coating  of  the  tongue  more  than  a  milk  diet,  or  forms 
a  better  field  for  the  development  of  fermentation  bacteria,  which 
are  constantly  being  carried  down  to  the  stomach  to  excite  indigestion 
and  flatulency  there.  Listerine  and  hydrogen  peroxid  diluted  make 
most  satisfactory  and  cleansing  mouth  washes.  A  whalebone  bent 


TYPHOID  FEVER  483 

in  a  loop  forms  a  good  "  tongue  scraper,"  and  cleans  its  surface  thor- 
oughly. If  patients  are  too  feeble  to  rinse  the  mouth,  the  nurse 
should  swab  it  out  for  them  with  a  bit  of  cotton  moistened  with  an 
antiseptic.  Nurses  should  be  made  to  understand  the  importance  of 
this  simple  detail,  for,  if  properly  attended  to,  it  adds  greatly 
to  the  patient's  comfort  and  appetite.  When  this  is  faithfully  done, 
one  seldom  sees  even  in  fatal  cases  a  typical  "  typhoid  tongue " — 
brown,  dry,  hard,  fissured,  and  so  stiff  that  it  is  useless  to  the  pa- 
tient. Patients  can  often  learn  to  use  a  tongue  bath  to  advantage 
—  that  is,  to  hold  the  mouth  full  of  fluid  for  several  minutes  at  a 
time,  when  much  moisture  is  absorbed  by  the  mucous  membrane. 
The  proper  care  of  the  mouth  will  lessen  the  liability  to  parotitis 
and  catarrh  of  the  middle  ear. 

The  Stomach. —  The  dangers  of  overfeeding  with  milk  have  been 
considered  upon  page  475.  Milk  disagrees  with  many  patients  sooner 
or  later,  and  the  fermentation  processes  of  which  it  is  capable  pro- 
duce large  quantities  of  gas  and  sometimes  elevation  of  temperature. 
Small  doses  of  salicin  or  cerium  oxalate  with  each  tumbler  of  milk 
may  prevent  dyspepsia,  and  the  milk,  if  pasteurized,  may  be  re- 
tained and  digested  where  vomiting  has  been  extreme.  If  there  is 
the  least  indication  of  ordinary  milk  disagreeing,  it  should  be  changed 
at  once  for  some  other  form  —  pancreatinized,  diluted,  or  boiled. 
With  a  clean  tongue,  and  with  sterilized  milk  in  the  stomach,  much 
may  be  done  to  favor  the  further  digestion  of  milk  in  the  intestine. 

The  Intestine. —  Many  typhoid  patients  are  constipated  by  an  ex- 
clusive milk  diet.  Constipation  favors  abnormal  fermentation,  and 
begets  the  flatulency  which  is  so  injurious.  Such  patients  should 
not,  as  a  rule,  be  allowed  to  go  more  than  twenty-four  hours  without 
obtaining  a  movement  with  an  enema.  The  judicious  daily  use  of  rec- 
tal enemata  does  not  excite  intestinal  hemorrhage,  and  excessive  consti- 
pation provokes  meteorism,  stretches  the  thin  ulcerating  surfaces  to  the 
point  of  rupture,  and  tends  to  keep  the  temperature  elevated.  If  re- 
lapses are  due  to  reinfection  or  simple  septic  absorption  through  ulcer- 
ating intestinal  surfaces,  there  is  all  the  more  reason  for  the  prevention 
of  accumulation  of  food  waste  in  the  intestine. 

Convalescence 

As  the  fever  subsides,  it  becomes  an  important  question  how  soon 
to  permit  a  return  to  solid  food.  Eelapses  may  be  induced  by  indis- 
cretion in  this  regard. 

The  patient's  appetite  is  always  a  dangerous  guide  to  follow  in 
this  disease.  After  four  or  five  weeks  of  an  exclusive  milk  or  milk 


484  DIET  IN   INFECTIOUS  DISEASES 

and  broth  diet,  when  the  temperature  subsides,  and  often  before  it 
has  become  normal,  he  becomes  ravenous.  Like  a  long-starved  man, 
he  thinks  of  nothing  but  food,  and  demands  something  new  to  eat 
every  day.  A  hospital  ward  containing  a  dozen  convalescing  typhoid- 
fever  patients  is  difficult  to  manage,  as  a  bread  riot  is  constantly 
menaced.  Ill-advised  but  sympathetic  friends  attempt  to  smuggle  in 
all  manner  of  forbidden  fruits,  and  the  patient  just  arrived  at  the 
hungry  stage  is  tempted  to  steal  solid  food  from  his  more  advanced 
neighbor. 

In  the  milder  cases  it  is  undoubtedly  both  safe  and  wise  to  allow  a 
strengthening  diet  at  an  early  date,  and  it  may  prolong  convalescence 
to  forbid  it.  Light  farinaceous  diet  —  tapioca,  rice,  vermicelli, 
cream  toast,  a  cracker  soaked  in  cream,  etc. —  may  be  given  with  im- 
punity in  cases  which  have  run  a  mild  course  as  soon  as  the  tempera- 
ture remains  normal  during  the  greater  part  of  the  day.  Meat  broths 
may  be  thickened  with  rice,  sago,  or  vermicelli.  In  a  day  or  two  more 
the  soft  part  of  oysters  or  a  chop  are  permissible.  In  cases  which 
have  presented  no  serious  complications,  if  there  is  good  stomach 
digestion  there  is  no  need  of  prolonging  a  fluid  diet  for  fear  of  intes- 
tinal injury. 

A  better  guide  for  feeding  than  the  temperature  alone,  is  the  pres- 
ence of  these  conditions:  a  clean  tongue,  a  soft  abdomen,  normal 
stools,  a  good  pulse  rate,  a  good  appetite,  and  a  brightening  facial 
expression  and  sensorium.  In  such  cases  I  am  accustomed  to  begin 
the  use  of  semisolid  feeding  several  days  before  the  temperature  is 
absolutely  normal  and  have  seen  no  harm  result. 

The  following  is  a  list  of  foods  suitable  for  the  different  days  of 
convalescence,  commencing  a  day  or  two  after  the  disappearance  of  all 
fever.  Milk  should  be  given  in  lessening  quantity  until  gradually 
entirely  replaced  by  solid  food. 

CONVALESCENT    TYPHOID    FEVEE   DIET 

First  Day. —  Chicken  broth  thickened  with  thoroughly  boiled  rice. 
Milk  toast  or  cream  toast  once  only  during  the  day.  Beef  juice, 
orange  juice,  weak  tea,  coffee,  or  cocoa. 

Second  Day. —  Junket,  mutton  broth,  and  bread  crumbs.  Cocoa. 
Milk  toast.  A  piece  of  tender  steak  may  be  chewed  but  not  swal- 
lowed. One  of  the  prepared  farinaceous  foods,  such  as  Mellin's  or 
Horlirk's,  may  be  given  with  a  cup  of  hot  milk. 

77?  inl  Day. —  A  small  scraped-beef  sandwich  at  noon.  A  soft- 
cookod  e<:<r  or  baked  custard  for  supper.  Boiled  rice  or  potato  puree 
strained.  Arrowroot  gruel. 


TYPHOID  FEVER  485 

Fourth  Day. —  The  soft  part  of  three  or  four  oysters.  Meat  broth 
thickened  with  a  beaten  egg.  Cream  toast.  Rice  pudding  or  blanc- 
mange and  whipped  cream,  or  Bavarian  cream. 

Fifth  Day. —  Scraped-beef  sandwich.  A  tender  sweetbread.  Bread 
and  milk.  A  poached  egg.  Wine  jelly  or  calf's-foot  jelly.  Macaroni. 

Sixth  Day. —  Mush  or  crackers  and  milk,  scrambled  eggs,  chicken 
jelly.  Bread  and  butter.  The  soft  parts  of  oysters,  stewed  in  milk. 

Seventh  Day. —  A  small  piece  of  tenderloin  steak  or  a  little  breast 
of  broiled  chicken.  Bread  and  butter.  Boiled  rice,  Wine  jelly. 
Sponge  cake  and  whipped  cream. 

Eighth  Day. —  A  slice  of  tender  rare  roast  beef,  a  thoroughly  baked 
mealy  potato  served  with  butter  or  mashed  with  cream.  Other  foods 
as  before. 

Ninth  Day. —  A  little  broiled  fresh  fish  for  breakfast.  Beefsteak 
at  dinner.  Rice,  macaroni,  eggs.  Sago,  rice,  or  milk  pudding.  A 
baked  apple. 

Tenth  Day. —  Cornmeal  "  mush  "  or  hominy  and  milk.  A  squab  or 
breast  of  partridge  or  roast  chicken.  Other  foods  as  before.  Ice 
cream. 

Daily. —  An  orange  and  weak  tea,  coffee,  or  cocoa. 

For  the  next  four  or  five  days  the  patient  may  select  articles  from 
the  menu  of  the  previous  day,  so  that  three. good  meals  a  day  are 
taken,  besides  three  or  four  glasses  of  milk  or  diluted  cream  between 
meals. 

(See  the  use  of  alcohol  in  fevers,  p.  470,  and  the  diet  for  con- 
valescence of  fever  in  general,  p.  472.) 

Rules  for  Feeding  in  Atypical  Cases. —  If  at  any  time  during  con- 
valescence after  several  days  of  a  normal  temperature  it  begins  to  rise 
above  100°  F.  it  is  safest  to  return  at  once  to  fluid  diet.  If  the  tem- 
perature falls  again  in  a  day  or  two,  convalescent  diet  may  be  resumed. 
A  sudden  rise  to  103°  F.,  or  even  higher,  lasting  but  a  day  or  two, 
may  be  caused  only  by  constipation,  and  it  is  not  to  be  considered  as 
a  genuine  relapse,  but  until  the  cause  is  ascertained  the  above  pre- 
caution should  be  observed. 

There  is  a  class  of  patients  in  whom  the  thermometric  record  is 
likely  to  fail  as  a  guide  for  feeding  unless  it  is  correctly  interpreted. 
After  a  protracted  fever  lasting  four  or  five  weeks  the  temperature 
falls  to  about  100°  F.  and  fluctuates  daily  up  to  100.5°  or  101.5°  F. 
without  reaching  the  normal,  or  it  may  become  subnormal  and  fluc- 
tuate between  97.5°  or  98°  F.  in  the  morning,  and  101°  F.  in  the 
afternoon.  These  patients,  in  the  absence  of  any  sequela?  to  account 
for  the  temperature  elevation,  have  a  "  starvation "  or  "  inanition " 


486  DIET  IN   INFECTIOUS  DISEASES 

fever,  and  are  usually  considerably  emaciated.  It  is  necessary  to  give 
them  solid  food  cautiously  to  bring  the  temperature  to  normal.  Some- 
times even  then  the  fever  lasts  until  they  are  allowed  to  sit  up. 

In  estimating  the  proper  time  for  giving  solid  food,  regard  should 
always  be  paid  to  the  previous  general  severity  of  the  disease. 

Complications,  such  as  an-  abscess  or  furunculosis,  may  protract 
the  fever,  although  the  intestinal  ulcers  are  completely  healed,  and 
patients  having  such  symptoms  should  have  solid  food  in  spite  of  a 
slight  elevation  of  temperature.  Patients  who  have  been  very  ill  with 
repeated  hemorrhage  or  hyperpyrexia  should  be  fed  with  the  greatest 
caution  during  convalescence. 

Many  recent  writers  among  those  with  largest  clinical  experience 
with  typhoid  fever  advocate  a  liberal  diet  throughout  the  disease  in 
ordinary  uncomplicated  cases,  instead  of  milk  alone,  and  giving  semi- 
solid  food  before  the  temperature  has  become  normal.  I  have  adopted 
this  practice,  with  benefit  in  many  selected  cases.  Relapses  are  rarely, 
if  ever,  induced  by  judicious  increase  in  diet,  and  the  patient  is  often 
better  able  to  withstand  a  relapse,  having  been  strengthened  with  more 
food.  As  a  sample  of  a  liberal  dietary,  such  as  that  above  referred  to, 
Frederick  W.  Shattuck's  may  be  quoted;  he  recommends  for  use 
throughout  the  fever  such  articles  as  the  following  named : 

Milk,  hot  or  cold,  with  or  without  salt,  diluted  with  lime  water, 
soda  water,  Apollinaris,  Vichy,  peptonized  milk,  cream  and  water,  milk 
with  white  of  egg,  slip,  buttermilk,  koumiss,  zoolak,  whey,  milk  with 
tea,  coffee,  cocoa.  Soups:  Beef,  veal,  chicken,  tomato,  potato,  oys- 
ter, mutton,  pea,  bean,  squash;  carefully  strain  and  thicken  with  rice 
(powdered),  arrowroot,  flour,  milk  or  cream,  egg,  barley.  Horlick's 
and  Mellin's  food,  malted  milk,  panopeptone,  bovinine,  somatose. 
Gruels :  Strained  cornmeal,  crackers,  flour,  barley  water,  toast 
water,  albumen  water,  with  lemon  juice.  Ice  cream.  Eggs,  soft- 
boiled  or  raw,  eggnog.  Finely  minced  lean  meat,  scraped  beef;  the 
soft  part  of  raw  oysters ;  soft  crackers  with  milk  or  broth.  Soft  pud- 
dings without  raisins;  soft  toast  without  crust;  blancmange,  wine 
jelly,  apple  sauce,  and  macaroni. 

Many  so-called  "  relapses  "  are  not  relapses  at  all,  in  the  accepted 
sense,  but  are  cases  of  mixed  infection  or  some  form  of  auto-intoxica- 
tion. Of  course,  it  would  not  be  maintained  that  a  diet  of  corned 
beef  and  cabbage  may  not  produce  great  intestinal  havoc  and  perhaps 
induce  fatal  hemorrhage,  but  I  do  maintain  that  a  carefully  increased 
dietary  such  as  that  described -is  not  a  cause  of  relapse.  I  have  seen 
many  dietetic  misfits,  in  which  overzealous  friends  had  smuggled 
improper  food  to  hospital  patients  (as,  for  example,  the  eating  of 


TYPHOID  FEVER  48T 

an  entire  bouquet  of  roses  and  violets,  left  by  a  friendly  Flower  Mis- 
sionary on  the  pillow  of  a  ravenous  young  hospital  patient),  yet  with- 
out producing  relapse,  and  on  the  contrary,  many  relapses  occur  while 
the  patient  is  still  only  taking  a  milk  diet. 

Typhoid  fever  is  essentially  a  disease  of  so-called  "  relapses." 
About  10  per  cent  of  all  cases  are  followed  by  relapse,  no  matter 
what  the  treatment.  It  fell  to  my  lot  to  treat  some  two  hundred 
cases  of  typhoid  fever  among  the  soldiers  who  returned  from  the 
Spanish  War,  and  I  was  much  impressed  by  the  comparatively  slight 
effect  which  a  perfectly  irrational  camp  diet  had  upon  them  —  re- 
lapses were  not  more  common  among  them  than  the  average,  which 
merely  shows  that  the  ulcerated  intestine  may  be  more  tolerant  of  food 
than  is  generally  supposed. 

At  the  end  of  a  fortnight  of  normal  temperature,  if  the  bowels  are 
moving  regularly  and  if  there  is  no  diarrhoea,  the  patient  may  usually 
be  allowed  to  select  his  own  menu,  although  he  must  be  warned  to 
avoid  for  a  long  time  eating  food  likely  to  leave  much  insoluble  resi- 
due, such  as  raw  vegetables,  raw  apples,  soft-shell  crabs,  berries,  green 
corn,  old  peas,  beans,  cabbage,  tough  meats,  dried  fruits,  etc.  He 
should  be  instructed  also  not  to  excite  diarrhoea  by  eating  too  much 
fresh  fruit.  With  any  attack  of  indigestion  he  should  return  for  a 
few  days  to  a  very  simple  diet. 

Typhoid  Fever  in  Children 

Typhoid  fever  in  young  children  is  rare.  When  it  occurs  in  in- 
fants between  two  and  five  years  of  age  they  should  be  fed,  if  possi- 
ble, exclusively  upon  milk  in  some  form,  predigested  if  necessary,  and 
pasteurized.  Children  usually  take  koumiss  well  and  thrive  upon  it. 

If  milk  be  refused,  and  emaciation  threatens  in  consequence,  some 
concession  should  be  made  in  the  rigor  of  the  diet,  but  of  course  no 
solid  food  is  permissible.  Beef  juice,  beef,  mutton,  or  chicken  broths 
(not  thickened),  and  beaten  egg  albumen  sweetened,  may  be  sub- 
stituted for  milk  or  alternated  with  it.  Children  take  junket  well. 

As  a  rule  they  need  no  alcohol  unless  they  are  very  feeble,  or  if 
complications  arise.  The  nurse  should  offer  water  freely.  Barley 
water  with  a  little  orange  or  lemon  juice  is  useful  to  relieve  thirst. 

The  temperature  curve  of  typhoid  fever  in  children  is  often  very 
irregular,  as  it  is  in  the  aged,  and  a  fall  to  near  the  normal  should  not 
be  regarded  as  justifying  an  allowance  of  solid  food  at  once,  and  no 
matter  how  clamorous  the  child  may  be  for  it,  the  same  strict  rules 
should  be  enforced  as  in  the  case  of  adults,  and  for  the  same  length  of 
time  during  convalescence. 


488  DIET  IN  INFECTIOUS  DISEASES 

TYPHUS  FEVER 

In  general  the  dietetic  treatment  of  typhus  fever  should  be  the 
same  as  that  of  typhoid  fever,  but  as  intestinal  ulceration  is  absent 
from  the  former,  the  extreme  care  of  the  alimentary  canal  is  less  im- 
perative. The  fever  is  high  and  the  patient  is  usually  delirious, 
hence  an  exclusive  milk  diet  is  best  during  the  height  of  the  fever, 
provided  it  is  well  digested.  The  duration  of  this  fever  is  much 
shorter  than  that  of  typhoid  fever,  and  some  of  the  objections  to  a 
milk  diet  are  therefore  less  prone  to  arise.  From  four  to  six  ounces 
of  milk  may  be  given  every  two  hours.  If  the  milk  is  not  well  as- 
similated it  may  be  alternated  with  or  supplemented  by  meat  broths, 
custard,  raw  eggs,  farinaceous  gruels,  etc. 

Abundant  water  should  be  offered,  and  the  tendency  to  ataxic  symp- 
toms and  stupor  may  be  counteracted  by  strong  black  coffee,  alcohol, 
etc. 

Convalescence. —  During  convalescence  the  precautions  observed 
in  the  treatment  of  typhoid  fever  are  not  necessary,  and  patients  may 
return  much  sooner  to  a  solid  diet ;  but  some  alcoholic  stimulant,  such 
as  ale  or  porter,  may  be  needed  with  meals.  The  directions  given  in 
the  section  on  Diet  in  Fever  in  General  (p.  465)  may  be  observed;  for, 
although  any  active  fever  may  leave  the  digestive  organs  somewhat 
enfeebled,  there  is  no  unusual  danger  of  this  kind  in  typhus  fever,  and 
relapses  are  not  occasioned  by  dietetic  errors. 

SMALLPOX 

The  invasion  of  smallpox  is  usually  abrupt,  and  the  temperature 
may  reach  104°  F.  on  the  first  day.  There  are  anorexia,  thirst, 
vomiting,  and  prostration,  in  addition  to  other  symptoms.  The  fever 
continues  for  three  days,  or  until  the  eruption  has  fully  developed, 
after  which  it  subsides.  During  the  febrile  stage  a  light  fluid  diet 
should  be  given,  such  as  is  recommended  for  fever  in  general  —  milk, 
broth,  gruel,  etc.  (p.  468).  The  thirst  is  relieved  by  offering  cool 
liquids  in  abundance,  such  as  water,  iced  lemonade,  Seltzer  water,  etc. 
If  there  is  much  eruption  in  the  throat,  there  may  be  considerable 
dysphagia. 

During  the  suppurative  stage  of  the  eruption  the  patient  requires 
an  abundant  supporting  diet,  and  as  much  milk,  cream,  custards,  milk- 
sugar,  eggs,  and  stimulating  meat  broths  should  be  prescribed  as  can 
be  digested.  The  patient  should  be  fed  at  least  once  every  two  hours, 
and  awakened  three  or  four  times  at  night  for  food.  Vomiting  is 


SCARLET  FEVER  489 

not  to  be  dreaded  after  the  onset  of  the  disease.  The  combined  effect 
of  the  irritation  of  so  large  a  cutaneous  eruption,  and  of  the  secretion 
of  so  much  pus  from  the  pustules,  which  may  amount  to  many  ounces, 
is  exhausting  to  the  last  degree,  and  earnest  effort  should  be  made  to 
counteract  it.  This  is  especially  true  of  all  confluent  cases.  A 
dozen  eggs,  three  quarts  of  milk,  and  a  half  pint  of  beef  juice  is  not 
too  much  to  order  for  an  adult.  These  materials  may  be  given  alone 
or  in  combination  with  alcohol,  as  eggnog,  milk  punch,  etc.  If  the 
stomach  rebels  against  so  much  food,  the  rectum  may  be  utilized  for 
part  of  the  work.  (See  Nutrient  Enemata,  p.  450.) 

This  supporting  treatment  should  in  all  grave  cases  be  commenced 
early,  even  in  the  vesicular  stage  of  extensive  eruption,  without  wait- 
ing for  signs  of  exhaustion,  which  are  otherwise  certain  to  follow. 
If  strong  liquor  is  not  tolerated,  champagne  or  other  wine  may  be 
substituted. 

Convalescence  occupies  from  one  to  four  weeks,  according  to  the 
severity  of  the  attack.  The  diet  should  be  increased  slowly,  and 
should  comprise  abundant  animal  food,  meat,  milk,  and  eggs,  and 
mild  alcoholic  beverages,  such  as  ale,  porter,  or  Burgundy. 

SCARLET  FEVER 

In  mild  cases  of  scarlet  fever  the  temperature  subsides  in  a  few 
days,  and  after  that  time,  during  the  period  of  desquamation,  special 
care  in  the  diet  is  unnecessary  unless  nephritis  be  present.  While 
the  fever  lasts  the  diet  should  be  of  fluid  character,  and  milk,  diluted 
cream,  koumiss,  vegetable  purees  and  soups,  and  farinaceous  gruels 
of  arrowroot,  farina,  etc.,  are  to  be  given.  In  all  cases  there  is  liability 
to  renal  irritation,  and  desquamative  nephritis  may  occur;  and  in 
order  to  eliminate  the  scarlatinal  poison  and  waste  products  of  the 
fever  from  the  system  as  rapidly  as  may  be,  it  is  advisable  that  the 
patient  take  as  little  proteid  food  as  possible,  except  milk,  and  drink 
large  quantities  of  fluid.  Dryness  of  the  mouth  and  thirst  are  prom- 
inent symptoms,  and  there  is  often  difficulty  in  swallowing,  owing  to 
the  inflamed  condition  of  the  throat.  Water, 'effervescing  waters 
(Seltzer,  Apollinaris),  barley  water,  orange  juice  in  Vichy,  and  sour 
lemonade  may  be  drunk  in  considerable  quantities.  Plain  vanilla  ice 
cream  is  much  enjoyed  by  children.  It  is  nutritious,  cooling,  and 
acceptable  to  the  parched  throat. 

If  the  temperature  is  high,  four  or  five  ounces  of  fluids  should  be 
given  every  two  hours.  In  severe  cases  there  is  gastric  derangement, 
and  the  diet  should  be  restricted  to  milk  in  some  form,  as  koumiss  or 
34 


490  DIET  IN   INFECTIOUS  DISEASES 

pancreatinized  milk.  If  nephritis  is  present,  the  milk  diet  should  be 
continued.  Jaccoud  maintains  that  scarlatinal  nephritis  may  be 
averted  by  keeping  the  child  upon  an  exclusive  milk  diet  from  the  com- 
mencement and  continuing  it  for  several  weeks.  (See  Acute  Nephri- 
tis, p.  544.) 

Convalescent  children  who  have  had  very  mild  attacks  are  often 
hungry,  but  it  is  best  to  control  their  diet  carefully  for  two  or  three 
weeks,  even  if  albuminuria  be  not  detected.  They  may  be  given  at 
first  such  articles  as  junket,  rice  pudding,  crackers,  farina,  corn  starch 
or  sago  with  cream,  milk  toast,  cream  toast,  baked  custard,  blanc- 
mange, wine  and  lemon  jelly,  cornmeal  mush,  baked  apples,  stewed 
prunes,  oranges.  The  resumption  of  animal  fare  should  be  very  grad- 
ual in  all  cases,  and  fish,  oysters,  chicken,  or  eggs  should  be  given 
before  red  meat. 

MEASLES 

The  diet  in  ordinary  cases  of  measles  does  not  require  special  care 
beyond  that  described  under  the  section  on  Diet  in  Fever  in  General 
(p.  465).  The  appetite  is  usually  wanting  in  the  prodromal  and  erup- 
tive stages  and  milk  with  farinaceous  gruels  answers  every  require- 
ment. Thirst  is  acute,  and  cool  water  or  lemonade  may  be  offered,  or 
orange  juice  or  unfermented  grape  juice  in  Vichy.  Alcoholic  stimu- 
lation is  only  needed  if  the  patient  is  very  feeble,  or  if  severe  com- 
plications arise.  The  resumption  of  a  solid  diet  should  be  gradual, 
but  may  begin  as  soon  as  the  fever  and  catarrhal  symptoms  disappear. 

When  nursing  or  hand-fed  infants  have  measles  they  should  be 
fed  somewhat  oftener  than  usual,  and  given  less  food  at  each  feeding. 
A  child  of  eight  or  ten  months  of  age  should  be  fed  on  diluted  milk 
like  one  two  or  three  months  younger.  In  this  manner  any  catarrh 
of  the  stomach  is  less  likely  to  cause  serious  indigestion  and  vomit- 
ing. It  is  particularly  necessary  to  give  water,  and  half  an  ounce 
should  be  offered  at  least  every  two  hours,  or  oftener,  while  the  in- 
fant is  awake. 

If  there  be  much  gastric  irritation  or  catarrh,  it  may  prove  best  to 
suspend  milk  feeding  for  a  day  or  two  and  substitute  meat  juice  or 
beef,  chicken,  or  mutton  broth. 

MUMPS 

For  mumps  no  special  diet  is  required  beyond  the  necessity  of  giv- 
ing fluids  or  soft  food  while  the  swelling  of  the  parotid  glands  and 


WHOOPING  COUGH  —  INFLUENZA  491 

fever  last.  The  suggestions  for  the  dietetic  treatment  of  tonsillitis 
(p.  564)  apply  to  this  disease.  Anaemia  is  apt  to  be  present  during 
convalescence,  and  meats,  eggs,  and  cream  should  therefore  be  sup- 
plied plentifully.  Cod-liver  oil  is  appropriate  in  protracted  conva- 
lescence. 

WHOOPING  COUGH 

In  whooping  cough  the  paroxysms  of  coughing  are  so  severe  as 
to  give  rise  to  vomiting,  and  in  intense  cases  they  are  excited  by  tak- 
ing food  which  does  not  have  an  opportunity  to  become  assimilated, 
and  nutrition  may  suffer  seriously  in  consequence,  adding  to  the 
general  exhaustion  which  accompanies  the  disease.  All  food  should 
be  made  easily  assimilable.  It  is  best  to  give  food  regularly  in  mod- 
erate quantity  at  each  time,  and  it  should  be  predigested  if  necessary. 
Pancreatinized  milk,  koumiss,  the  predigested,  malted,  and  other 
amylaceous  foods  (p.  189),  cream  toast,  eggs,  junket,  chicken  broth, 
custard,  milk  puddings,  and  gruels  thickened  with  meat  extracts. 
Stimulants  in  the  form  of  egg  albumen  in  sherry,  eggnog,  or  milk 
punch,  are  recommended  for  adult  patients  who  vomit  solid  food. 
The  worst  cases  require  nutrient  enemata  (p.  450),  as  exhaustion  be- 
comes critical. 

INFLUENZA 

Symptoms. —  Influenza  is  an  acute  infectious  fever  which  is  recog- 
nized by  catarrhal  inflammation  of  the  mucous  membranes  of  the 
upper  air  passages  and  alimentary  canal,  and  by  symptoms  referable 
to  the  nervous  system.  In  many  cases  the  symptoms  are  mild  and 
of  short  duration,  and  no  special  dietetic  treatment  is  required  beyond 
that  common  to  febricula  (p.  465),  but  a  large  number  of  cases  are 
accompanied  by  a  variety  of  serious  complications  or  present  sequela?. 
In  the  majority  of  instances  the  mucous  membranes  of  the  air  pas- 
sages are  the  principal  seat  of  the  inflammation,  but  in  others  the 
gastrointestinal  mucous  membranes  are  similarly  attacked,  giving 
rise  to  pronounced  digestive  disorders,  nausea,  vomiting,  and  diar- 
rhoea. The  fever,  commonly  of  moderate  severity  (103°  to  103.5° 
F.),  persists  for  three  or  four  days  or  a  week  or  more.  There  is 
usually  great  depression  of  spirits,  with  extreme  malaise,  muscular 
pains,  enfeebled  circulation,  and  almost  total  loss  of  appetite. 

Dietetic  Treatment. —  While  the  fever  persists,  the  stomach  is 
usually  irritable,  and  the  diet  should  be  fluid.  Food  should  be  given 
in  small  quantities. 


492  DIET  IN   INFECTIOUS  DISEASES 

In  grave  cases  it  is  necessary  to  prescribe  an  exclusive  milk  diet 
for  the  first  two  or  three  days,  and  two  and  a  half  quarts  should  be 
drunk  if  possible.  Later  the  patient  may  be  given  nourishing  beef, 
mutton,  or  chicken  broths,  with  beaten  eggs  added,  milk  toast,  cream, 
milk  sugar,  custards,  eggnog,  and  milk  punch.  As  soon  as  solid  food, 
can  be  eaten,  scraped-beef  sandwiches,  oysters,  tender  breast  of 
chicken,  eggs  poached  or  scrambled,  and  light  farinaceous  articles  with 
which  cream  is  taken,  are  appropriate. 

As  a  stimulant,  champagne  is  particularly  serviceable  in  relieving 
both  the  physical  and  mental  depression  which  is  so  characteristic  of 
nearly  all  phases  of  this  disease. 

Convalescence  is  frequently  prolonged,  and  debility,  muscular  weak- 
ness, irritability  of  the  heart,  and  enfeeblement  of  digestion  are  often 
present  to  a  degree  which  appears  disproportionate  to  the  inten- 
sity and  duration  of  the  febrile  attack.  The  diet  should  therefore 
still  be  supervised  carefully,  while  every  exertion  of  either  body  or 
mind  is  prohibited.  The  food  should  be  of  a  highly  nutritious  char- 
acter and  served  in  an  appetizing  and  palatable  manner,  and  as  abun- 
dant as  the  condition  of  the  stomach  will  allow.  (For  details  see 
Convalescence  from  Typhoid  Fever,  p.  484.) 

Patients  with  whom  milk  usually  agrees  do  well  to  take  it  in  quanti- 
ties amounting  to  a  quart  a  day,  in  addition  to  abundant  solid  proteid 
food,  roast  beef,  beefsteak,  chicken,  eggs,  etc. 

Alkaline  waters  should  be  drunk.  If  the  appetite  flags  and  return 
of  strength  is  delayed,  tonics  and  possibly  change  of  air  may  be  re- 
quired. 

When  convalescence  is  protracted  it  is  advisable  to  continue  alco- 
holic stimulation,  and  milk  punches,  eggnog,  plain  whisky  and  water, 
or  a  glass  of  sound  Burgundy  may  be  given  two  or  three  times  a  day, 
as  a  tonic,  with  the  meals.  Malt  liquors  may  be  indicated. 

SUMMARY  OF  ADDITIONAL  FOODS  FOR  INFLUENZA 

(1)  Acute    Stage. —  Gruels:      Barley,    rice,    farina,    arrowroot, 
strained  oatmeal,  mucilage  of  rice,  flaxseed  tea,  junket,  cream  toast, 
malted  milk,  grannm,  beef  essence,  beef  meal  (p.  132),  Eskay's  food, 
meat  juice,  bouillon  with  dropped  egg,  chicken  jelly,  lemonade,  orange- 
ade, whey,  posset,  koumiss,  cocoa. 

(2)  Convalescent  Stage. —  Omelette,  shirred  eggs,  baked  custard, 
snow  pudding  (of  eggs  and  milk),  whipped  cream  and  sponge  cake, 
plain  blancmange,  chocolate,  custard  or  blancmange,  rice  pudding, 
sago,  tapioca,  baked  apples,  brandy  and  egg  mixture,  Stoke's  cognac 
niixturr.  caudle,  malt  and  rice,  hominy  and  Indian  meal,  macaroni, 


DIPHTHERIA  493 

lemon  and  coffee  jelly  (besides  the  meats  enumerated  above).     (For 
all  receipts  see  Receipts  for  Invalid  Diet.) 

DIPHTHERIA 

Symptoms. —  Diphtheria  is  an  acute,  infectious  disease  character- 
ized by  croupous  inflammation  of  mucous  membranes  which  particu- 
larly affects  the  pharnyx  and  upper  air  passages.  Clinically  the 
disease  presents  fever  of  an  irregular  type,  with  great  debility,  and  fre- 
quently albuminuria.  Anemia  and  rapid  loss  of  flesh  and  strength 
are  characteristic.  Death  may  result  from  toxaemia,  sudden  heart 
failure,  obstruction  to  the  entrance  of  air  caused  by  accumulation 
of  the  diphtheritic  membrane,  the  extension  of  the  inflammation 
down  the  air  passages,  or  exhaustion  from  inability  to  swallow  food. 
Eecovery  is  uniformly  slow,  and  may  be  still  further  retarded  by 
paralysis  or  other  sequelae.  Owing  to  the  extent  to  which  the  throat 
is  involved,  with  consequent  difficulty  in  swallowing,  and  to  the  gen- 
eral weakness  and  prostration,  there  are  few  diseases  in  which  greater 
care  in  regard  to  dietetic  treatment  becomes  imperative.  There  is 
anorexia,  and  the  sense  of  taste  is  lost;  nausea  is  frequently  present 
as  well  as  constipation.  The  cervical  lymphatic  glands  are  more  or 
less  swollen  and  give  rise  to  pain  or  soreness  on  opening  the  mouth. 
Albumin  may  appear  in  the  urine  as  early  as  the  second  day. 

Dietetic  Treatment. —  All  food  should  be  given  in  fluid  form,  of 
which  milk  is  the  best,  or  if,  as  sometimes  happens,  semisolid  mate- 
rial is  more  easily  swallowed,  the  food  may  be  thickened  with  cream, 
gelatin,  eggs,  or  farinaceous  articles;  or  beef  meal,  Mellin's  food, 
malted  milk,  granum,  etc.,  may  be  added  for  this  purpose  to  other 
foods.  The  diet  should  consist  chiefly  of  nutritious  beef  or  chicken 
broth  and  beef  tea,  egg  albumen,  eggnog,  milk,  and  milk  punch. 
Plain  vanilla  ice  cream  is  nutritious,  and  if  not  too  sweet  it  is  well 
borne,  and  is  frequently  very  acceptable  to  the  inflamed  throat.  Sim- 
ple farinaceous  foods,  such  as  arrowroot,  thoroughly  cooked  rice,  soft 
cream  toast,  and  gruels,  may  be  taken.  Continued  disgust  for  food 
is  a  very  bad  prognostic  sign,  and  every  effort  should  be  made  to  coun- 
teract it  by  offering  variety. 

Intubation  and  Tracheotomy 

Since  the  use  of  diphtheria  antitoxine  became  general,  these  opera- 
tions are  very  seldom  required. 

When  intubation  of  the  larynx  has  been  performed  the  child  some- 
times experiences  great  trouble  in  swallowing  without  drawing  food 


494  DIET   IN   INFECTIOUS  DISEASES 

into  the  trachea.  It  is  difficult  to  close  the  epiglottis  with  the  tube  in 
position,  or  to  draw  up  the  larynx  beneath  the  root  of  the  tongue  to 
the  extent  which  should  occur  in  normal  deglutition,  and  hence  fluid 
food  particularly  is  liable  to  trickle  through  the  tube  into  the  trachea, 
exciting  violent  dyspnoea  and  spasms  of  coughing.  Semisolid  food 
or  solid  food,  such  as  junket,  cormneal  mush,  or  eggs,  is  more  liable 
to  glide  over  the  instrument  without  being  sucked  in  through  it  dur- 
ing inspiration.  The  late  Dr.  O'Dwyer  said :  "  Solids  and  semi- 
solids,  when  there  is  an  appetite  for  such  food,  and  when  the  patients 
can  be  induced  to  take  it,  are  swallowed  much  better  than  fluids,  and 
do  not  enter  the  tube,  as  far  as  I  am  aware";  and  he  added  that  a 
bolus  of  food  tends  to  press  the  epiglottis  down  over  the  tube,  while 
fluid  tends  to  raise  it,  or  slip  in  under  it,  although  he  modified  the  head 
of  the  tube  by  giving  it  a  concave  surface  to  fit  the  epiglottis. 

Very  young  infants,  who  are  dependent  upon  a  milk  diet,  can 
swallow  best  if  laid  upon  the  back  across  the  nurse's  lap  with  the 
head  downward,  supported  below  her  knees.  While  in  this  position 
the  bottle  is  given,  so  that  the  child  may  "  swallow  up-hill."  Re- 
gurgitation  through  the  nose  may  occur,  but  that  is  of  little  moment 
compared  with  the  accident  of  inhaling  the  milk  through  the  tube  into 
the  lungs. 

In  older  children,  when  proper  precautions  are  taken  in  regard  to 
the  position  of  the  head  in  swallowing  and  the  avoidance  of  inspira- 
tion at  the  same  time,  these  dangers  may  be  overcome  by  the  passage 
of  an  cesophageal  tube,  though  this  irritates  the  throat  and  may 
spread  the  diphtheritic  membrane  along  the  oesophagus.  Intelligent 
children  may  learn  to  swallow  well  with  a  little  practice  and  care  while 
wearing  the  intubation  tube.  Some  even  swallow  easier  than  before 
its  insertion  by  reason  of  the  relief  of  dyspnoea,  which  always  makes 
deglutition  difficult.  In  other  cases  the  tube  may  be  removed  tem- 
porarily, if  the  dyspnoea  be  not  extreme,  while  the  child  takes  nourish- 
ment; but  this  requires  skilled  attendance,  and,  as  the  patient  ought 
to  be  frequently  fed,  it  possesses  disadvantages.  As  a  rule,  the  longer 
the  tube  remains  in  position,  the  better  the  patient  acquires  facility 
in  swallowing.  In  some  cases  it  may  be  well  to  resort  to  rectal  ali- 
mentation for  a  day  or  two. 

It  should  not  be  forgotten  with  very  young  children  that  a  failure 
to  take  food  may  be  due  to  loathing  or  nausea,  and  not  to  physical 
inability  to  swallow  with  the  tube  in  situ.  O'Dwyer  wrote:  "I  al- 
ways instruct  children  who  are  old  enough  to  understand,  to  drink  as 
rapidly  as  they  can,  and  then  cough  to  expel  any  fluid  which  may 
have  entered  the  tube,  instead  of  coughing  after  each  deglutition,  as 


CEREBRO-SPINAL   MENINGITIS  495 

they  usually  do."  He  discountenanced  the  theory  that  food  may 
enter  the  tube  and  excite  pneumonia  by  reaching  the  deeper  portions 
of  the  lungs,  and  said :  "  I  do  not  believe  —  and  there  is  no  evidence 
so  far  to  prove  —  that  any  of  the  fluid  entering  the  tube  ever  reaches 
the  bronchi,  for  it  is  promptly  expelled  by  coughing."  He  cited  cases 
in  support  of  this  statement,  one  being  that  of  a  woman  who  wore  the 
iaryngeal  tube  for  over  ten  months  continuously,  and  enjoyed  good 
health.  He  said  that  vomited  food  enters  the  tube  less  often  than 
swallowed  food. 

Tracheotomy. —  The  operation  of  tracheotomy  is  performed  for 
obstructions  of  various  kinds,  such  as  accumulation  of  diphtheritic 
membrane  in  the  larynx,  oedema  of  the  glottis,  Iaryngeal  new  growths, 
etc.  The  conditions  which  require  this  procedure  are  usually  among 
those  which  interfere  to  a  greater  or  less  extent  with  swallowing, 
although  the  presence  of  the  tracheotomy  tube  in  the  trachea  is  well 
borne  and  does  not  necessarily  conflict  with  deglutition  in  any  man- 
ner. No  special  precautions  in  feeding  are  necessitated  by  the  pres- 
ence of  the  tube,  as  in  the  case  of  intubation. 

Post-Diphtheritic  Paralysis 

In  post-diphtheritic  paralysis  the  soft  palate  is  oftenest  affected, 
but  the  muscles  of  the  tongue  and  pharynx,  or  even  the  oesophagus, 
also  may  be  involved,  in  which  case  deglutition  is  hindered.  Semi- 
solid  or  solid  food  usually  can  be  swallowed  better  than  fluids,  pro- 
vided it  is  made  into  an  adhesive  bolus  with  butter,  syrup,  etc.,  or 
made  slippery  with  gelatin.  It  may  be  necessary  to  feed  the  patient 
wholly  or  in  part  through  a  catheter  or  stomach  tube  (see  Gavage) 
or  by  enemata.  (See  Enemata,  p.  489.) 

The  phenomenal  success  of  antitoxin  inoculations  in  reducing  the 
mortality  of  diphtheria  to  less  than  one-third  of  its  former  degree 
have  made  sequelae  of  this  nature  very  infrequent,  as  well  as  the 
necessity  of  intubation  and  tracheotomy. 

CEREBRO-SPINAL  MENINGITIS 

Symptoms. —  Cerebro-spinal  meningitis  is  an  infectious  disease  in 
which  the  chief  lesions  are  an  inflammation  of  the  meninges  of  the 
brain  and  spinal  cord,  which  results  in  the  production  of  a  variety 
of  symptoms,  including  fever,  disturbances  of  the  nervous  and  mus- 
cular systems,  nausea,  vomiting,  and  constipation.  The  symptoms 
vary  greatly  in  severity  and  duration,  lasting  from  a  few  days  to  sev- 
eral months.  In  mild  cases  convalescence  is  established  at  the  end 


496  DIET   IN   INFECTIOUS  DISEASES 

of  a  week,  but  in  serious  and  protracted  cases  the  nervous  symptoms 
increase  in  severity.  The  stage  of  excitement  and  irritation  of  the 
nerves  with  active  delirium  is  succeeded  by  profound  prostration  and 
coma,  with  progressive  emaciation,  a  variable  temperature,  and  paraly- 
sis of  the  sphincters,  with  involuntary  evacuations.  Such  cases  as  a 
rule  prove  fatal,  but  they  are  not  necessarily  hopeless,  and  recovery 
may  take  place  at  any  time,  especially  if  the  Flexner  specific  meningo- 
coccus  serum  be  used  early  in  the  disease.  Much,  therefore,  depends 
upon  the  careful  nourishment  of  the  patient. 

Dietetic  Treatment. —  In  simple  cases  a  liquid  diet  of  milk,  broth, 
meat,  and  egg  albumen,  with,  perhaps  a  little  toast  or  crackers,  may 
be  given  while  acute  symptoms  last.  In  protracted  grave  cases,  and 
especially  where  convulsions,  delirium,  and  coma  are  present,  patients 
should  be  fed  with  great  care,  and  all  nourishment  given  in  frequent 
small  doses  and  an  easily  assimilable  form.  Sometimes  forced  feed- 
ing with  the  stomach  tube  is  required.  Pancreatinized  meat  broth, 
and  milk,  albumoses,  and  beef  juice  may  be  ordered,  if  necessary, 
every  hour.  In  extremely  feeble  patients  such  fluids  are  administered 
in  teaspoonful  doses,  or  even  in  smaller  quantities,  with  a  medicine 
dropper,  by  which  they  are  passed  between  the  closed  teeth.  It  also 
is  advisable  to  employ  rectal  alimentation.  There  is  no  lesion  of  the 
alimentary  canal,  and  consequently  in  those  cases  in  which  larger 
quantities  of  food  nourishment,  or  even  solid  food,  can  be  taken  there 
is  no  objection.  If  the  patient  be  able  to  eat  and  swallow  properly, 
milk  toast,  scraped  beef,  eggs,  custard,  wine  jelly,  farina,  Bavarian 
cream,  blancmange,  etc.,  are  indicated.  Water  may  be  given  ad 
libitum  to  relieve  the  thirst,  which  is  often  intense. 

Convalescence  will  be  promoted  by  giving  abundance  of  food.  Five 
or  six  meals  a  day  may  be  taken.  The  appetite  is  frequently  good 
from  the  commencement  of  convalescence.  Beefsteak,  chops,  roast 
beef,  mutton,  or  chicken,  bread  and  butter,  oatmeal,  porridge,  hominy, 
baked  or  mashed  potato,  rice  with  cream,  and  cocoa  may  be  allowed  as 
soon  as  the  patient's  digestion  permits. 

ERYSIPELAS 

Symptoms. —  Erysipelas  is  an  infectious  disease  characterized  by 
high  fever  and  intense  local  inflammation  of  the  skin  and  contiguous 
mucous  membranes.  There  is  prostration  and  enfeeblement  of  the 
heart  and  circulation. 

Dietetic  Treatment. —  The  indications  for  dietetic  treatment  are  to 
support  the  strength  by  stimulants  and  nutritious  foods  adapted  for 


CHOLERA  497 

easy  digestion.  When  the  temperature  is  high,  and  nausea  and  vomit- 
ing exist,  nourishment  should  be  taken  in  small  quantities  —  an 
ounce  or  two  at  a  time  every  hour  by  day.  In  ordinary  cases,  pan- 
creatinized  milk,  beef  juice  or  albumoses  and  beef  broth,  eggnog,  milk 
punch,  and  farinaceous  gruels  are  recommended.  Aged  or  debilitated 
persons  especially  need  alcoholic  stimulation  in  the  form  of  diluted 
whisky.  After  the  local  inflammation  subsides  the  period  of  con- 
valescence requires  a  very  nutritious  diet,  and  fluids  may  gradually  be 
replaced  by  beef,  soft-cooked  eggs,  toast,  bread  and  butter,  and  light 
farinaceous  foods  with  cream,  mashed  or  baked  potatoes,  baked  apple, 
custards,  blancmange,  and  chocolate. 

If  the  disease  invade  the  pharynx,  an  exclusive  milk  diet  is  neces- 
sary, and  alcoholic  stimulants  as  well  as  medicines,  except  those  de- 
signed for  local  treatment,  should  be  given  per  rectum  to  avoid  in- 
creasing the  local  irritation. 

CHOLERA 

Dietetic  Prophylaxis. —  Cholera  is  a  zymotic  disease,  the  germs  .of 
which  can  only  enter  the  system  by  the  mouth,  and  they  are  spread 
through  the  agency  of  contaminated  water  used  for  drinking  or 
washing  purposes.  All  raw  foods  and  cooking  utensils  washed  in 
such  water  are  liable  to  become  infected. 

No  raw  food  or  drink  of  any  kind  whatsoever  should  be  taken.  It 
is  customary  for  the  local  health  boards  to  prohibit  the  sale  of  raw 
fruits  while  a  cholera  epidemic  is  in  progress,  and  it  is  a  standard  rule 
to  cook  all  food  and  boil  the  drinking  water. 

Tea,  coffee,  chocolate,  and  cocoa  should  be  made  only  with  water 
previously  sterilized  by  boiling,  and  sterilized  water  exclusively  should 
be  used  for  cleansing  the  teeth.  Water  should  not  be  cooled  by  direct 
contact  with  ice,  or  the  latter  should  be  made  from  distilled  water. 
No  beer,  ale,  soda  water,  or  artificial  mineral  waters  should  be  used  if 
there  is  any  chance  of  contaminated  river  or  well  water  having  entered 
into  their  manufacture.  Milk  may  become  infected  from  washing  the 
milk  cans  in  impure  water.  Eating  utensils,  plates,  cups,  etc.,  should 
not  be  washed  in  unboiled  water. 

Acid  beverages  should  be  freely  drunk,  for  the  cholera  germs  do 
not  thrive  in  acid  media,  and  if  accidentally  introduced  into  the 
stomach  they  may  perish  there  if  the  gastric  contents  always  has 
an  acid  reaction.  Sour  lemonade  made  with  ten  or  fifteen  drops  of 
dilute  sulphuric  acid  has  an  excellent  reputation  as  a  prophylactic. 
Vinegar,  sour  pickles,  or  lime  juice  may  be  taken  for  the  same  purpose. 


498  DIET  IN  INFECTIOUS  DISEASES 

Indigestion,  perhaps  because  it  promotes  alkaline  fermentation  in 
the  stomach,  favors  infection,  and  hence  during  the  prevalence  of  an 
epidemic  it  is  desirable  to  eat  only  plainly  cooked,  wholesome  food, 
and  avoid  all  excesses  in  eating  and  drinking.  All  foods,  such  as 
pastry,  fried  dishes,  etc.,  having  the  reputation  of  easily  disagreeing 
should  be  eschewed.  It  is  important  to  avoid  eating  anything  likely 
to  produce  diarrhoea,  and  all  indigestible  substances,  such  as  meat, 
eggs,  fish,  or  milk  not  strictly  fresh,  unripe  or  overripe  fruit  and  veg- 
etables, must  be  absolutely  forbidden. 

Symptoms. —  The  symptoms  of  cholera  are  divisible  into  four 
periods.  1.  The  premonitory  diarrhoea.  2.  The  period  of  profuse 
serous  diarrhoea.  3.  The  algid  stage,  or  that  of  collapse  or  asphyxia. 
4.  The  reactionary  stage. 

The  dietetic  treatment  varies  v/ith  each  period. 

First  Period. —  There  is  alkaline  watery  diarrhoea  with  frequent 
profuse  stools,  nausea  and,  usually,  vomiting.  The  stomach  is  too 
irritable  to  retain  food,  and  undigested  broths  and  milk  furnish  cul- 
ture media  for  development  of  the  cholera  bacilli  and  production  of 
toxins.  Only  light  fluid  food  in  very  small  quantity  should  be  eaten. 
Nothing  can  be  worse  than  overeating.  Whey,  egg  albumen,  gruels, 
or  bouillon  are  permissible. 

The  contents  of  the  stomach  should  be  kept  acid,  and  sour  lemon- 
ade, lime  juice,  dilute  acid  phosphates,  dilute  vinegar,  and  dilute 
hydrochloric  acid,  twenty  or  thirty  drops  in  a  half  tumblerful  of 
water,  or  diluted  aromatic  sulphuric  acid  in  similar  dosage,  are  to  be 
swallowed  from  time  to  time,  alone  or  with  lemonade.  The  acids 
should  be  given  through  a  glass  tube  to  spare  the  teeth,  or  the  mouth 
may  be  rinsed  with  a  soda  solution  after  taking  them. 

Hyperacidity  of  the  stomach  artificially  produced  favors  the  pas- 
sage of  a  portion  of  the  acid  stomach  contents  into  the  small  intestine, 
so  that  its  normal  alkalinity,  to  some  extent,  is  neutralized,  and  the 
duodenum  temporarily  may  acquire  an  acid  reaction. 

Second  Period. —  The  stools  become  more  frequent  and  serous, 
They  are  almost  continuous,  and  enormous  quantities  of  fluid  are 
rapidly  drained  from  the  system,  in  which  whitish  flakes  of  desqua- 
mated intestinal  epithelium  are  suspended.  Sometimes  they  contain 
blood.  As  much  as  two  quarts  of  fluid  may  be  discharged  in  a  single 
evacuation.  Nausea  and  epigastric  distress  occur  with  projectile 
vomiting  of  fluid,  which  exceeds  in  quantity  that  which  is  drunk. 
Intense  abdominal  cramps  follow  and  extend  down  the  legs.  The 
patient  rapidly  emaciates,  and  feebleness  and  prostration  are  ex- 
treme. There  is  a  cold,  clammy  perspiration,  and  in  a  few  hours 


YELLOW  FEVER  499 

the  victim  passes  into  collapse.  Active  efforts  must  be  made  to 
stop  the  vomiting  and  diarrhoea.  The  abdomen  should  be  incased  in 
flannel,  and  turpentine  stupes  are  of  service  if  the  cramps  are  severe. 
A  mustard  paste  may  be  placed  over  the  epigastrium,  and  a  hypo- 
dermic injection  of  morphine  is  required.  Cracked  ice,  cold  lime 
water,  iced  champagne  and  carbonic-acid  water,  iced  fresh  lime  juice 
in  Vichy,  weak  cold  brandy  and  Seltzer,  or  plain  soda  —  are  all  good 
remedies  which  should  be  offered  in  very  small  doses  every  five  or 
ten  minutes.  Strong  black  coffee  may  be  tried.  The  thirst  may  be 
assuaged  by  dilute  hydrochloric  acid  or  lemon  juice  in  water.  A 
little  fluid  held  in  the  mouth  for  a  few  minutes  sometimes  affords 
more  relief  of  this  symptom  than  larger  quantities  swallowed.  It 
is  worse  than  useless  to  attempt  to  give  even  predigested  milk  while 
the  vomiting  and  diarrhoea  continue. 

Third  Period. —  In  both  the  second  and  third  stages  the  best  re- 
sults are  obtained  by  the  method  of  hypodermoclysis  —  that  is,  of 
hypodermic  injections  into  the  sides  of  the  abdominal  wall  and  be- 
low the  breast  of  large  quantities  of  normal  salt  solution  made  by 
dissolving  60  grains  (a  scant  teaspoonful)  of  salt  to  the  pint  of  boiled 
water.  The  injections  are  given  at  the  temperature  of  the  blood,  and 
the  entire  quantity  may  be  used  in  the  course  of  half  an  hour.  The 
salt  solution  replaces  to  some  extent  the  fluid  drained  by  the  serous 
diarrhoea  and  emesis,  restores  the  blood  pressure  and  equilibrium  of 
the  circulation,  and  almost  immediately  relieves  the  thirst. 

Fourth  Period. —  If  vomiting  ceases  and  the  symptoms  of  collapse 
abate,  a  little  fluid  nourishment  may  very  slowly  and  cautiously  be 
tried.  A  teaspoonful  or  two  of  pancreatinized  milk,  koumiss,  Liebig's 
or  Valentine's  meat  extract,  or  fresh  beef  juice  is  first  given.  If  this 
is  retained,  the  dose  is  to  be  repeated  and  continued  by  increasing  the 
quantity  and  diminishing  the  frequency  of  administration  as  the  pa- 
tient improves.  The  stomach  remains  feeble  and  irritable  for  many 
days,  and  for  a  week  or  two  it  may  be  necessary  to  limit  the  diet  to 
pancreatinized  milk,  beef  albumoses,  nutritious  broths,  egg  albumen 
in  diluted  brandy,  and  champagne.  The  further  dietetic  treatment 
may  be  conducted  in  the  manner  of  that  of  the  convalescence  of  ty- 
phoid fever  (p.  483). 

YELLOW  FEVER 

Symptoms. —  Yellow  fever  is  an  acute,  infectious  disease  charac- 
terized by  a  sharp  febrile  paroxysm,  gastric  hemorrhage,  jaundice 
and  suppression  of  urine.  The  nature  of  the  symptoms  is  exceed- 


500  DIET  IN   INFECTIOUS  DISEASES 

ingly  acute  and  intense,  and  during  the  active  progress  of  the  infec- 
tion digestion  becomes  impossible.  The  liver  presents  the  lesions  of 
parenchymatous  hepatitis,  and  its  functional  activity  is  completely 
suspended.  The  whole  alimentary  canal  presents  the  picture  of  acute 
catarrh,  but  the  stomach  particularly  is  softened,  swollen,  and  ecchy- 
motic,  and  may  be  eroded. 

The  disease  presents  three  different  stages,  the  dietetic  treatment 
of  each  of  which  is  important,  viz. :  1.  The  cold  period,  followed  by 
febrile  reaction.  2.  Eemission  or  "  stage  of  calm."  3.  Exacerba- 
tion, with  a  uraemic  condition  or  else  collapse. 

The  first  stage  begins  with  vomiting  and  great  prostration.  The 
slightest  pressure  over  the  epigastrium  excites  projectile  vomiting. 
Constipation  is  present  from  inability  to  retain  fluids;  the  mouth 
becomes  dry,  the  gums  sore  and  swollen,  and  thirst  is  extreme.  The 
urine  is  much  diminished  in  volume  as  the  changes  in  the  liver 
progress,  and  the  bile  ducts  are  blocked  with  degenerated  epithelium; 
the  bile  enters  the  blood,  and  the  skin  and  conjunctivas  become 
jaundiced. 

After  several  days  —  usually  four  or  five  —  these  symptoms  sub- 
side and  the  second  period  is  reached.  The  duration  of  this  period 
seldom  exceeds  two  days,  and  may  continue  only  a  few  hours.  It 
is  a  condition  of  calm,  in  which  all  symptoms  are  abated;  the  fever, 
which  may  previously  have  existed,  subsides  and  gastric  irritation  is 
lessened. 

In  the  third  period  the  symptoms  of  the  first  period  return  with 
renewed  severity,  and  in  addition  a  condition  of  uraemia  develops. 
Hemorrhage  of  the  stomach,  known  as  "black  vomit,"  is  present  in 
about  one-third  of  the  fatal  cases.  The  vomited  material  ejected 
during  the  course  of  the  disease  consists,  first,  of  whatever  food  the 
stomach  may  contain,  then  of  bile-tinged  mucus,  and  finally  of  a  deep 
brown  or  black  acid  semifluid  substance  resembling  coffee  grounds, 
which  consists  of  red  blood-corpuscles,  pigment  granules,  degenerated 
mucus,  epithelial  cells,  leucocytes,  fatty  matter,  and  serous  fluid. 
The  quantity  of  this  fluid  may  reach  several  pints.  The  blood 
from  the  passively  congested  surface  oozes  freely  from  the  capillary 
walls  of  the  gastric  mucous  membrane.  The  stools  are  black  and 
diarrhccal.  The  urine  becomes  very  scanty,  and  may  be  suppressed 
entirely.  There  is  hsematuria. 

Should  recovery  result,  the  jaundice  continues  for  some  days,  but 
the  other  symptoms  subside  gradually  and  convalescence  is  always 
slow  and  may  ho  retarded  by  various  complications,  among  the  most 
serious  of  which  arc  an  exceedingly  irritable  stomach  and  intestine. 


YELLOW  FEVER  501 

Errors  in  diet  have  been  known  to  cause  fatal  hemorrhage  from 
the  stomach  as  long  as  a  fortnight  or  three  weeks  after  beginning 
convalescence.  Irritability  of  the  stomach  may  even  persist  for  sev- 
eral months  after  the  subsidence  of  all  other  symptoms.  This  brief 
account  of  the  more  important  features  of  the  disease  emphasizes  the 
necessity  for  careful  dietetic  management. 

Treatment  of  the  First  Period. —  The  patient  immediately  should 
be  placed  in  bed  and  kept  absolutely  quiet.  Best  in  a  recumbent 
position  is  to  be  carefully  enjoined,  and  the  patient  must  not  be 
allowed  to  even  raise  the  head  to  drink.  Medicine  and  fluids  may 
be  given  through  a  tube  or  with  a  teaspoon.  If  the  patient  is  seen 
promptly,  and  there  is  a  probability  of  undigested  food  being  pres- 
ent in  the  stomach,  that  organ  should  be  unloaded  by  an  emetic.  If 
constipation  be  present  the  bowels  should  be  emptied  by  a  purgative 
enema.  It  is  generally  considered  that  profuse  perspiration  is  an 
advantage.  This  object  may  be  accomplished  by  covering  the  patient 
with  blankets  and  giving  a  hot  lemonade  or  hot  toddy,  such  as  hot 
whisky  and  water  with  lemon  juice. 

As  the  vomiting  becomes  more  and  more  intense  it  is  best  to  let 
the  stomach  have  absolute  rest,  which  is  secured  by  hypodermic  injec- 
tions of  morphine,  mustard  paste  over  the  epigastrium,  and  the  choice 
of  the  rectum  for  all  medication.  Among  the  various  dietetic  means 
at  command  for  the  relief  of  the  vomiting  are  cracked  ice,  light 
acidulated  or  effervescing  draughts,  such  as  acid  lemonade,  lime  juice, 
and  Vichy,  Seltzer,  or  carbonic  water,  strong  coffee,  and  plain  lime 
water  in  frequent  half-ounce  doses  given  cold.  Iced  champagne,  very 
dry  Mumm  or  Pommery  sec,  or  lemonade  with  bitartrate  of  potassium, 
may  be  retained.  With  the  supervention  of  uraemic  symptoms,  or 
when  there  is  suppression  of  urine,  there  is  urgent  need  of  getting 
more  fluid  into  the  body.  If  aerated  waters  are  not  tolerated  by  the 
stomach,  two  or  three  pints  of  salt  water  should  be  injected  into  the 
rectum  every  two  hours,  or  hypodermoclysis  may  prove  of  service  after 
the  manner  employed  in  cholera  (p.  499).  While  the  fever  lasts,  or 
throughout  the  first  period,  it  is  usually  best  not  to  give  food  at  all, 
for  the  stomach  is  almost  certain  to  reject  or  fail  to  digest  it. 

Many  cases  of  yellow  fever  develop  among  previously  healthy  per- 
sons who  can  withstand  the  absence  of  food  for  a  day  or  two  with- 
out serious  loss,  provided  exhausting  symptoms  can  be  held  in  check. 
In  many  instances,  however,  prostration  and  exhaustion  occur  with 
extraordinary  rapidity,  and  in  an  hour  the  patient  may  be  too  feeble 
to  articulate  or  move.  Active  stimulation  by  the  rectum  and  hypo- 
dermically  is  then  necessary.  For  this  purpose  whisky  is  best.  It 


502  DIET  IN   INFECTIOUS  DISEASES 

should  be  injected  hypodermically  with  a  sterilized  syringe  in  quan- 
tities of  one  to  three  drachms.  The  injections  may  be  made  beneath 
the  skin  on  the  outer  surface  of  the  thigh  and  arms  in  four  or  five 
places.  Two  ounces  of  whisky  diluted  in  an  equal  part  of  water  or 
strong  black  coffee  may  be  injected  per  rectum. 

Treatment  of  the  Second  and  Third  Periods. —  During  the  interval 
of  the  second  period  abatement  of  the  fever  and  of  the  gastric  irri- 
tation may  admit  of  a  little  nourishment  being  taken  by  the  stomach. 
Some  patients  recover  without  passing  into  the  third  period,  but 
because  many  do  not,  extreme  caution  must  be  observed  and  food, 
if  taken  at  all,  should  be  in  minute  quantities.  The  same  rules  in 
regard  to  diet  and  stimulants  apply  to  the  third  period  which  have 
been  prescribed  for  the  first,  and  the  main  reliance  for  nourishment 
should  be  through  rectal  alimentation.  When  the  paroxysm  is  over 
and  the  symptoms  have  abated,  the  greatest  care  should  still  be 
exercised  in  regard  to  diet  even  if  the  patient  is  hungry.  In  the 
gravest  cases  no  solid  food  should  be  permitted  for  at  least  ten  days 
or  a  fortnight,  for  fatal  relapses  have  been  precipitated  by  not  ob- 
serving this  rule.  When  the  vomiting  and  epigastric  pain  have 
ceased,  half-teaspoonful  or  teaspoonful  doses  may  be  given  once  in 
fifteen  minutes  of  pancreatinized  milk,  egg  albumen,  koumiss,  Lie- 
big's  or  Valentine's  meat  extract,  iced  dry  champagne,  or  good  Khine 
wine.  If  such  foods  are  retained,  they  may  be  followed  after  some 
hours  by  a  few  spoonfuls  of  pressed  beef  juice,  salted,  and  later  by 
warm,  nourishing  beef  or  chicken  broth,  gruels,  or  buttermilk.  Stim- 
ulating or  nutrient  enemata  should  still  be  ordered,  because  in  the 
early  stages  of  convalescence  the  stomach  will  not  tolerate  all  the 
food  which  the  impoverished  tissues  require.  Epigastric  fullness  or 
distress,  or  tympanites,  should  be  regarded  as  a  warning,  and  food 
should  be  withheld  again  until  the  difficulty  is  corrected  by  antacids 
or  antifermentatives.  It  is  to  be  noted  that  children  usually  require 
rectal  feeding  and  stimulation  earlier  than  adults. 

In  mild  cases,  after  four  or  five  days,  and  in  severe  cases  after 
a  fortnight,  solid  food  may  be  given  occasionally,  commencing  with 
milk  toast,  crackers,  junket  and  cream  custard,  farina  and  boiled  or 
broiled  chicken,  soft-cooked  eggs,  wine  jelly,  boiled  rice,  and  scraped 
beef.  Fruits  and  vegetables  should  not  be  allowed  for  several  weeks. 

SEPTIC^MIA 

In  chronic  septic  conditions  the  diet  should  be  as  nutritious  as 
possible.  In  active  febrile  cases  food  should  be  in  fluid  form,  but 


MALARIA  503 

in  very  chronic  cases  and  those  accompanied  by  prolonged  local 
suppuration  easily  digestible  solid  food  —  such  as  broiled  fish  or 
beefsteak  or  chicken,  oysters,  toast,  light  bread  and  butter,  and  light 
farinaceous  articles  with  cream  —  may  be  allowed.  The  directions 
given  in  the  article  upon  the  Diet  of  Fever  in  General  (p.  465),  and 
Typhoid  Convalescence  (p.  483)  are  applicable,  and  if  the  patient 
improves,  the  stimulating  diet  recommended  for  some  cases  of  tuber- 
culosis (see  Dietetic  Treatment  of  Tuberculosis,  p.  505)  is  recom- 
mended. 

Fat  foods  should  predominate  largely  in  the  diet,  such  as  butter, 
diluted  cream,  and  eggs. 

MALARIA 

Intermittent  Fever. —  The  dietetic  management  of  malarial  fevers 
consists  of  the  treatment  during  the  paroxysms  and  of  that  between 
them.  In  intermittent  fever  the  paroxysms,  although  severe,  are 
comparatively  brief.  Vomiting  often  accompanies  the  chill.  If  the 
patient  is  disinclined  to  take  food  there  is  nothing  to  be  gained  by 
forcing  it  upon  him,  and  the  stomach  may  be  allowed  to  rest  for 
a  day.  Otherwise  a  glass  of  hot  milk  or  cup  of  broth  may  be  offered. 
When  the  paroxysm  is  over,  if  the  appetite  returns,  solid  food  may 
be  given  without  much  restriction.  If  a  patient  has  had  several 
attacks  at  brief  intervals  he  is  usually  both  anaemic  and  constipated, 
and  the  subsequent  diet  should  contain  a  liberal  proportion  of  animal 
food  to  counteract  the  former  condition,  and  of  fresh  fruits  and 
green  vegetables  for  the  latter. 

Remittent  Fever. —  In  remittent  malarial  fever,  which  is  more  pro- 
tracted than  the  intermitting  type,  feeble  digestion  may  be  a  promi- 
nent symptom,  requiring  a  milk  diet  while  the  fever  is  at  its  height. 
The  Diet  of  Fever  in  General  (p.  465)  covers  the  need  of  these 
cases. 

Patients  with  malarial  fever  are  inclined  to  resort  too  freely  to 
the  whisky  bottle,  and  overstimulation  in  the  continued  fevers  is  a 
common  fault.  Only  the  severer  forms  of  Southern  and  tropical 
agues,  bilious  remittent  fever,  etc.,  require  alcohol.  The  dietetic 
treatment  of  the  latter  corresponds  with  the  directions  given  for  that 
of  yellow  fever  (pp.  501-2). 

Malarial  cachexia  demands  dietetic  treatment  for  anaemia  and  con- 
stipation. Among  the  most  useful  foods  are:  roast  beef,  beeksteak, 
mutton,  chicken,  bacon,  bread  and  butter,  oatmeal,  hominy,  cornmeal, 
cream,  spinach,  tomatoes,  lettuce,  celery,  string  beans,  onions,  aspara- 


504  DIET  IN   INFECTIOUS  DISEASES 

gus,  squash,  baked  or  stewed  -apples,  stewed  prunes  or  figs,  oranges, 
grapefruit,  peaches  and  plums. 


TETANUS 

Symptoms. —  Tetanus  is  an  acute  infection  produced  by  the  tetanus 
bacillus  which  enters  the  body  through  an  abraded  surface,  develops 
toxins  in  the  system,  and  causes  exaggerated  irritability  of  the  central 
nervous  system.  The  ordinary  reflex  action  from  peripheral  excita- 
tion is  so  far  intensified  that  the  slightest  pressure  on  the  surface 
of  the  body,  or  change  in  surrounding  temperature,  or  even  a  loud 
sound,  may  throw  the  patient  into  violent  convulsions  and  painful 
tonic  spasms  and  attempts  to  swallow  may  induce  them.  The  muscles 
of  the  lower  jaw  are  set  in  rigid  contraction,  making  it  impossible 
for  the  patient  to  open  the  mouth  to  take  food,  and  forcible  efforts  to 
separate  the  teeth  may  excite  convulsions.  It  is  necessary  to  sup- 
port the  strength  by  every  available  means,  for  tetanus  is  not  in- 
variably a  fatal  disease,  especially  if  tetanus  antitoxin  be  given. 

Dietetic  Treatment. —  Food  can  be  given  only  in  liquid  form,  and 
if  a  front  or  side  tooth  is  absent  a  soft-rubber  catheter  may  be  passed 
in  between  the  set  teeth  and  fluid  be  poured  into  the  mouth  through 
it.  Milk,  egg  albumen,  eggnog,  nutritious  beef,  mutton,  or  chicken 
broths,  and  malted  gruels,  should  be  given  as  frequently  as  the  con- 
dition of  the  patient  will  permit.  If  possible,  from  two  to  four 
ounces  should  be  administered  every  hour.  These  foods  may  be 
strengthened  by  addition  of  beef  meal,  concentrated  meat  extracts, 
such  as  Eudische's  sarco-peptone,  sanatogen,  and  somatose.  Alco- 
holic stimulation  and  nourishment  may  be  given  by  the  rectum,  but 
this  method  is  as  likely  to  excite  convulsions  as  mouth  feeding.  If 
general  convulsions  are  induced  by  every  attempt  to  feed  the  patient, 
it  becomes  necessary  to  put  him  under  primary  anesthesia  by  the 
inhalation  of  chloroform,  and  then  a  tube  may  be  passed  into  the 
stomach,  through  which  twelve  or  sixteen  ounces  of  a  thick  soup  or 
precligested  milk,  eggnog,  and  stimulants  may  be  poured.  By  this 
means  he  is  disturbed  less  often  and  larger  quantities  of  nourishment 
are  given  at  one  time.  In  a  case  of  tetanus  which  came  under  my  ob- 
servation, the  muscular  spasms  were  intense  and  almost  continuous 
for  over  five  weeks.  The  difficulty  in  feeding  the  patient  was  ex- 
treme, and  emaciation  was  very  pronounced.  The  patient  complained 
incessantly  of  thirst,  and  often  of  hunger,  but  was  able  to  swallow 
milk  broths  and  stimulants  given  between  the  closed  teeth  in  fre- 
quent closes,  and  his  final  recovery  was  attributable  mainly  to  per- 


RABIES  —  TUBERCULOSIS  505 

sistent  efforts  at  careful  feeding,  chloroform  anaesthesia  having  been 
several  times  successfully  employed  to  relax  spasm. 


RABIES 

In  feeding  a  patient  with  rabies,  substantially  the  same  plan  is 
to  be  followed  as  that  above  described  for  tetanus  (p.  504).  In  some 
cases,  however,  even  in  the  early  stages,  all  efforts  to  swallow  fluid 
food  excite  violent  general  convulsions.  The  spasm  may  be  lessened 
by  application  of  cocaine  to  the  throat,  so  that  the  patient  can  swal- 
low. Failing  this,  nutrient  enemata  may  be  relied  upon,  but  they 
also  sometimes  excite  convulsions.  In  such  case  it  is  justifiable  to 
produce  primary  anaesthesia  with  chloroform,  and  to  seize  the  moment 
of  temporary  relaxation  for  feeding  by  gavage. 

TUBERCULOSIS 

Causation. —  Tuberculosis  is  an  infectious  disease,  due  to  the  pres- 
ence in  some  part  of  the  body  of  the  Bacillus  tuberculosis.  The  dis- 
ease may  be  either  acute  or  chronic,  but  fever  is  present  whenever 
there  is  an  exacerbation  of  the  symptoms.  The  latter  are  both  local 
and  general,  and  vary  with  the  particular  organ  or  organs  affected, 
but  the  lungs  constitute  by  far  the  most  frequent  site.  The  bacillus 
tuberculosis,  and  particularly  the  pus-forming  microorganisms  com- 
monly associated  with  it  in  the  lungs,  produce  toxins  which  modify 
nutrition,  causing  pyrexia  and  an  increased  production  of  tissue  waste,  • 
with  more  or  less  rapid  emaciation. 

Several  factors  combine  to  disturb  the  digestive  system.     These 
are: 

1.  The  fever  itself. 

2.  The  toxic  condition  of  the  blood,  which  affects  the  quality  and 
quantity  of  the  digestive  juices. 

3.  In  pulmonary  tuberculosis,  after  the  expectoration  becomes  con- 
siderable it  is  often  ropy  and  tenacious,  and  some  of  it  is  liable 
to  adhere  to  the  surface  of  the  mouth  or  pharynx,  and  be  swallowed 
with  the  food  or  saliva,  with  the  result  of  exciting  gastric  and  intes- 
tinal  catarrhs,   or  possibly  of   locally   infecting  the  mucous  mem- 
bfane   of   the   intestine   with   the   bacilli,   which   produce   ulceration 
with  further  impairment  of  digestive  functions  and  absorption. 

The  prognosis  of  a  given  case  depends  very  largely  upon  the  di- 
gestion and  assimilation  of  food. 

General  Consideration  of  Dietetic  Treatment. —  Proper  dieting  is 


506  DIET  IN  INFECTIOUS  DISEASES 

one  of  the  most  important  factors  in  the  prophylactic  as  well  as  the 
active  treatment  of  pulmonary  tuberculosis,  and  in  prescribing  a 
regimen  many  things  are  to  be  taken  into  consideration  besides  the 
mere  classification  and  selection  of  food.  The  disease  may  be  ex- 
ceedingly protracted,  lasting  for  years,  with  intervals  in  which  the 
patient  enjoys  a  comparative  degree  of  health  and  comfort,  which 
temporarily  emancipate  him  from  dietetic  restrictions.  But  even 
then  he  should  see  to  it  that  his  food  is  ample  for  his  bodily  needs. 
Malnutrition  at  any  time  may  permit  the  renewed  activity  of  a  latent 
tubercular  process,  and,  on  the  other  hand,  increase  in  body  weight 
is  accompanied  by  marked  improvement  in  the  symptoms  of  the 
disease. 

The  disease  being  very  chronic  the  pecuniary  circumstances  of  the 
patient  should  be  considered.  By  ordering  him  to  abandon  his  means 
of  livelihood  to  undertake  a  long  and  expensive  journey  he  may 
be  so  impoverished  that  he  cannot  afford  to  procure  the  best  food, 
and  good  climate  is  of  little  use  unless  it  helps  him  to  acquire  a 
better  appetite  and  easier  digestion. 

The  appetite,  too,  should  be  consulted.  It  is  sometimes  better  to 
humor  whims  than  to  seek  to  combat  them,  and  inflexible  rules  should 
not  be  enforced  for  dieting.  The  appetite  is  often  poor  or  capricious, 
and  the  physician's  dietetic  expedients  may  be  severely  taxed  to  de- 
vise suitable  foods  which  meet  all  requirements.  The  patient  should 
be  given  a  list  of  foods  which  he  regularly  may  eat,  foods  to  be  avoided, 
and  foods  which  he  may  have  as  an  occasional  indulgence,  so  as  not 
'to  waste  digestive  energy  upon  foods  of  low  potential  value. 

Young  phthisical  girls  especially  may  long  for  sweets  and  con- 
fectionery, and  despise  the  more  wholesome  animal  food;  in  fact, 
some  writers  regard  this  as  a  symptom  of  the  disease  in  such  cases. 
If  they  cannot  have  what  they  crave  they  will  refuse  what  they  are 
allowed,  and  tact  and  persuasion  are  required  to  induce  them  to  eat 
rationally. 

So  much  depends  upon  sustaining  the  nutrition  and  strength  of 
tuberculous  patients,  that  it  is  of  the  utmost  importance  to  keep  the 
stomach  and  bowels  in  the  best  possible  condition. 

Patients  should  be  warned  never  to  swallow  the  sputum,  for  this 
provokes  dyspepsia,  and  sooner  or  later  gastric  catarrh.  The  occur- 
rence of  the  latter  is  also  favored  by  the  habit,  which  many  patients  ac- 
quire, of  perpetually  taking  cough  medicines  and  patent  "  sure  cures," 
some  of  which  contain  potassium  iodide  and  other  gastric  irri- 
tants. 

All  food  should  be  fresh  and  carefully  selected,  and  the  cooking 


TUBERCULOSIS  507 

should  be  as  simple  as  possible  without  monotony.     Viands  should 
be  savory,  and  served  in  a  manner  to  tempt  the  palate. 

The  most  important  articles  of  diet  for  the  consumptive  are  the 
animal  foods,  and  milk,  eggs,  and  fats  and  oils  should  form  the 
essentials,  rather  than  too  much  meat;  but  in  ordinary  cases  any 
variety  of  properly  cooked  animal  food  may  be  eaten.  Starches 
and  sugars  are  allowable,  but  never  to  the  exclusion  of  proteid  ali- 
ments, and  not  at  all  if  gastric  catarrh  exists.  In  phthisis  there 
often  seems  to  be  a  failure  to  assimilate  completely  amylaceous  and 
saccharine  food,  which  is  beyond  that  which  is  explainable  by  the 
presence  of  catarrhal  conditions.  These  substances,  which  ordinarily 
furnish  a  large  proportion  of  the  energy  of  the  body,  in  tuberculosis 
appear  to  do  so  less  readily  than  the  fats  and  proteids.  Growing 
children,  however,  require  more  carbohydrates  than  do  adults.  Malt 
is  especially  valuable  as  a  tonic  in  tuberculosis,  and  diastase  aids 
assimilation  of  farinaceous  foods. 

Great  diversity  exists  among  different  phthisical  patients  in  the 
power  of  assimilation  of  food,  and  in  individual  cases  during  the 
progress  of  the  disease. 

Bauer  says :  "  One  not  infrequently  sees  phthisical  patients  who 
corfsume  the  full  hospital  diet  without  any  visible  ill  effects,  al- 
though their  evening  temperature  oscillates  between  102°  and  104° 
F.  With  such  patients  one  need  feel  no  anxiety  as  to  the  choice 
of  foods,  provided  their  nutritive  value  be  the  same." 

Rest  is  important  in  its  relation  to  digestion,  and  patients  should 
not  eat  when  fatigued.  Benefit  is  derived  by  lying  down  and  quietly 
resting,  even  without  sleeping,  for  half  or  three-quarters  of  an  hour 
before  dinner  and  supper.  It  is  best  to  take  the  principal  meal  in 
the  middle  of  the  day  unless  there  is  fever  at  that  time  or  soon 
after  it,  in  which  case  it  is  desirable  to  employ  the  intervals  when 
the  temperature  is  low  for  feeding.  Thus  it  may  happen  that  a  hearty 
meal  taken  between  7  and  10  A.  M.  is  better  digested  than  at  any  other 
time  of  day. 

Patients  should  avoid  eating  more  food  at  any  one  time  than 
they  can  digest  comfortably,  and  it  is  often  best  to  give  food  five 
or  six  times  in  twenty-four  hours  to  avoid  overworking  the  stomach. 
If  digestion  is  deficient,  only  one  article  of  food  should  be  given  at 
a  time,  or  else  only  such  varieties  of  food  as  require  the  same  length 
of  time  for  digestion  (p.  390),  and  patients  may  do  better  when  they 
eat  all  their  animal  food  at  one  meal  and  vegetable  food  at  another, 
having  regard  to  the  separate  action  performed  by  the  stomach  and 
intestines  upon  these  different  food  classes.  If  there  is  stomach 


508  DIET  IN   INFECTIOUS  DISEASES 

catarrh,  or  if  the  gastric  juice  is  weak,  the  quantity  of  fluid  taken 
with  meals  should  be  restricted  to  a  minimum,  excepting  in  very  ad- 
vanced cases,  in  which  the  diet  may  be  necessarily  entirely  fluid. 
But  half  a  pint  of  very  hot  water  may  be  taken  with  advantage  half 
an  hour  before  each  meal,  to  cleanse  and  stimulate  slightly  the  gastric 
mucous  membrane. 

The  late  A.  L.  Loomis  wrote:  "When  the  pressure  of  food  in 
the  stomach  excites  cough,  or  when  paroxysms  of  coughing  have  in- 
duced vomiting,  the  ingestion  of  food  must  be  delayed  until  the 
cough  ceases,  or  an  appropriate  sedative  may  be  employed.  In  those 
extreme  cases  where  every  attempt  at  eating  excites  nausea,  vomiting, 
and  spasmodic  cough,  excellent  results  are  attained  by  artificial  feed- 
ing through  the  soft-rubber  stomach  tube." 

Meats. —  Raw  beef  is  extolled  by  many  physicians,  especially  among 
the  French,  as  possessing  peculiar  nutritive  and  even  curative  value 
for  tuberculosis,  and  in  the  popular  mind  its  blood-red  color  and 
bright  red  juice  seem  to  suggest  an  intimate  connection  with  blood 
formation.  The  red  wines  are  erroneously  regarded  by  laymen  in 
the  same  light.  It  is  true  that  blood  and  muscle  have  great  similarity 
of  composition.  But  it  has  not  been  demonstrated  that  raw  meat 
possesses  any  advantage  over  rare  steak  or  underdone  roast  beef  "be- 
yond the  fact  that  the  scraping  and  mincing  process  to  which  it  is 
usually  subjected  prepares  it  somewhat  better  for  solution  by  the 
gastric  juice.  (See  Eaw  Meat,  p.  127.) 

Patients  will  often  take  scraped  raw-meat  balls  contentedly  for 
several  days,  and  then  acquire  a  distaste  for  them.  This  may  be 
overcome  by  seasoning  with  an  aromatic  herb,  such  as  thyme,  pars- 
ley, or  marjoram.  Yeo  suggests  that  when  made  into  small  balls 
the  meat  may  be  covered  with  powdered  sugar  or  gum,  and  swallowed 
with  a  sip  of  wine  or  brandy,  or  the  mouth  may  be  rinsed  with 
claret  to  remove  the  after-taste. 

Both  scraped  beef  and  the  various  preparations  of  beef  powder, 
beef  meal,  etc.,  are  useful  to  re-enforce  broths,  hot  milk,  milk  punch, 
or  light  soups  of  vermicelli,  tapioca,  etc.  According  to  Prof.  R.  H. 
Chittenclen,  the  nutritive  value  of  lean  beef  being  placed  at  100, 
that  of  beef  peptonoids  is  140  and  that  of  Mosquera's  beef  meal  is 
400.  If  preferred,  from  one  to  five  ounces  of,  beef  meal  may  be  eaten 
daily,  spread  like  jam  upon  bread  and  butter.  Insomnia  may  often 
be  prevented  by  taking  on  retiring  a  cup  of  hot  bouillon,  thick  clam 
broth,  or  gruel,  with  a  cracker  or  two. 

Beef  juice,  extracted  by  a  small  meat  press,  may  be  ordered  two 
or  throe  times  a  day.  It  may  be  seasoned  and  drunk  like  bouillon, 


TUBERCULOSIS  509 

or  eaten  as  a  luncheon  upon  dry  toast,  crackers,  or  boiled  rice.  (For 
the  method  of  preparation,  see  Beef  Juice,  p.  135.) 

It  is  often  desirable  to  give  dilute  hydrochloric  acid  and  a  little 
nux  vomica  after  the  ingestion  of  meat  or  other  animal  food  unless  it 
has  been  predigested. 

Eggs. —  Eggs  are  not  well  borne  if  there  is  dyspepsia  or  decided 
gastric  catarrh.  Otherwise  they  are  nutritious  and  wholesome.  They 
may  be  given  raw,  beaten,  or  very  lightly  cooked  in  hot  water,  but 
never  hard  boiled.  They  may  also  be  eaten  scrambled  or  as  an  omelet 
if  lightly  made.  Egg  albumen  may  be  digested  well  when  the  yolk 
proves  too  rich.  "  A  raw  egg  sucked  from  the  shell  will  often  relieve 
an  irritable  condition  of  the  larynx"  (H.  P.  Loomis). 

Cereals. —  Cereals  may  be  used  in  the  early  stage  of  the  disease, 
before  the  alimentary  canal  is  much  disturbed,  and  such  foods  as 
cornmeal  "  mush,"  farina,  oatmeal,  wheaten  grits,  puffed  rice,  hominy, 
or  germea  may  be  allowed  with  cream.  If  cream  and  sugar  disagree, 
they  may  be  eaten  with  lemon  juice.  Macaroni  is  wholesome,  and 
milk  sugar  should  be  tried. 

Fruits. —  The  succulent  fruits  are  well  borne  in  mild  cases,  and 
are  very  wholesome  and  nutritious.  Baked  and  stewed  apples  may 
be  given  with  cream.  Oranges,  plums  and  peaches  are  recommended. 

Fats  and  Oils. —  Fats  and  oils  are  indicated  in  tubercular  disease, 
and  especially  in  pulmonary  phthisis,  in  as  large  amounts  as  the 
patient  may  be  able  to  digest.  Crisp  fat  bacon,  butter,  cream,  egg 
yolk,  cod-liver  oil,  and  olive  oil,  all  furnish  desirable  forms  of  fat 
when  the  intestine  absorbs  them.  Kussell's  emulsion  of  mixed  fats 
is  a  very  digestible  preparation  by  which  to  administer  this  class  of 
food  (p.  230). 

While  fat  is  being  taken  it  is  well  occasionally  to  observe  the  stools 
to  see  that  none  passes  away  undigested,  and  if  any  one  fat  disagrees 
and  causes  dyspepsia  its  use  should  be  restricted,  or  temporarily 
withheld  while  another  is  tried.  As  a  rule,  cream  diluted  with  Vichy, 
butter  and  cod-liver  oil  will  prove  the  best.  If  a  patient  can  take 
one-quarter  pound  of  butter  a  day  it  furnishes  about  one-half  of  the 
necessary  heat  units.  Fats,  well  digested,  seem  in  some  instances 
to  have  an  almost  curative  power,  so  greatly  do  nutrition  and  body 
weight  improve  during  their  use. 

Cod-liver  Oil. — The  use  of  cod-liver  oil  in  phthisis  should  be  de- 
termined by  the  condition  of  the  digestive  organs  and  the  general 
nutrition  of  the  patient.  Wherever  the  digestion  is  fairly  good,  in 
the  absence  of  gastric  catarrh,  the  oil  is  of  great  nutritive  power,  and 
it  is  usually  well  borne  when  properly  administered.  If  there  is 


510  DIET  IN  INFECTIOUS  DISEASES 

much  gastric  catarrh,  or  if  the  stomach  is  irritable  and  nausea  is 
easily  excited,  persistence  in  the  use  of  the  oil  will  only  make  mat- 
ters worse.  It  is  on  the  whole  more  satisfactory  for  children  than 
adults,  particularly  in  cases  of  tuberculosis  in  which  the  bones  or 
glands  are  enlarged. 

The  presence  of  diarrhoea  is  usually  a  contraindication  for  the 
administration  of  cod-liver  oil,  but  unless  it  is  given  in  large  quan- 
tities it  has  very  little  if  any  laxative  effect  upon  adults,  and  it  may 
usually  be  continued  in  doses  of  a  drachm  two  or  three  times  a  day, 
with  no  ill  effect,  and,  in  fact,  by  improving  the  nutrition  it  may 
sometimes  benefit  diarrhoea.  Einger  suggests  that  by  this  class  of 
patients  a  teaspoonful  or  more  of  the  oil  given  at  night  before  sleep 
may  be  better  borne  than  at  any  other  time  in  the  day. 

Commonly  it  is  best  to  give  the  oil  pure  and  uncombined  if  it 
can  be  tolerated.  It  may  be  given  in  capsules,  although  they  are 
not  always  dissolved  at  the  proper  time  in  the  stomach.  (For  the 
many  different  methods  of  administering  it  and  of  disguising  its 
taste  see  Cod-liver  Oil,  p.  237).  The  isolated  active  principle  of  the 
oil,  called  gaduin,  has  been  employed  with  some  degree  of  suc- 
cess (p.  236).  As  a  substitute  for  cod-liver  oil,  I  often  prescribe 
cream  diluted  with  Vichy  or  carbonic  water  to  the  consistency 
of  milk,  i.  e.,  4  or  5  tablespoonfuls  of  cream  in  a  tumblerful 
of  Vichy. 

Alcohol. —  Alcohol  is  not  believed  to  possess  any  specific  action  in 
phthisis,  and  in  the  majority  of  cases  it  is  positively  harmful.  As  a 
rule,  if  patients  have  a  fair  appetite  and  are  improving  in  strength 
its  use  is  contraindicated.  When  alcohol  is  required  as  a  food  and 
tonic  rather  than  as  a  stimulant,  the  best  form  in  which  to  give  it 
is  that  of  malt  liquor  or  light  wine.  One  or  two  pints  daily  may  be 
prescribed  of  beer,  stout,  or  porter,  or  half  a  pint  of  claret  or  sound 
Burgundy.  The  light  Hungarian,  Italian,  or  Greek  wines  may  be 
used  by  those  whose  purse  places  them  within  reach.  One  of  the 
Tokay  wines,  with  cocoa,  may  be  prescribed.  Sherry,  port,  Madeira, 
and  champagne  are  less  desirable.  They  are  liable  to  disagree  and 
cause  dyspepsia  and  headache. 

The  habit  of  daily  drinking  rum,  whisky,  or  other  strong  liquors 
in  tuberculosis  cannot  be  too  strongly  condemned.  No  class  of  pa- 
tients exhibits  more  painfully  and  rapidly  the  inroads  of  the  disease 
than  those  \vbo  for  a  long  time  have  been  hardening  their  own  tissues, 
like  pathological  specimens,  with  daily  draughts  of  strong  alcohol. 
The  cirrhotic  changes  which  occur  in  various  organs  are  the  best 
possible  preparation  for  the  advancement  of  tubercular  processes.  If 


TTJBEECULOSIS  511 

the  exhibition  of  alcohol  increases  the  temperature  and  the  pulse  rate, 
and  is  followed  immediately  by  greater  weakness,  it  is  doing  harm. 

Diet  in  Mild  Cases 

The  following  liberal  menu  will  furnish  abundant  variety  from 
which  to  select  the  dietary  for  tuberculous  patients  in  whom  the 
progress  of  active  lesions  is  in  abeyance  or  completely  arrested,  and 
in  whom  there  is  little  or  no  gastric  catarrh.  Patients  should  eat 
all  they  can  digest,  especially  of  milk,  eggs,  and  butter,  and  should 
allow  five  hours'  interval  between  meals. 

FOODS  ALLOWED  IN  NON-ACTIVE  CASES  WITHOUT  GASTRIC  CATARRH 

Soups  and  broths:  Mutton,  oyster,  clam,  barley,  vermicelli,  bouil- 
lon, chicken  with  rice,  milk. 

Purees  of  peas,  beans,  tomatoes,  celery,  potatoes,  corn.  It  is  often 
well  to  add  to  them  meat  extracts,  peptonoids,  beef  meal,  or  eggs. 

Milk  or  cream  in  any  form,  including  buttermilk  and  koumiss, 
clotted  or  Devonshire  cream,  whipped  cream,  plain  ice  cream. 

Shellfish:  Oysters  or  clams,  either  raw,  roasted,  or  broiled  (the 
livers  or  "  soft  parts  "  only). 

Fish  of  any  kind  if  fresh,  either  boiled  or  broiled  (never  fried), 
sardines  (if  they  "  agree  ")  for  the  sake  of  the  oil. 

Eggs,  preferably  raw  or  very  lightly  cooked,  or  in  eggnog  or  cus- 
tard, also  poached,  scrambled,  dropped,  shirred,  or  in  plain  omelet 
(never  hard-boiled). 

Meats:  Beefsteak,  rare  roast  beef,  scraped-beef  sandwiches  or 
meat  balls,  lamb  or  mutton,  roasted  or  boiled;  chops;  chicken,  capon, 
turkey,  either  roasted,  boiled,  or  broiled,  ham,  tongue,  guinea  hen. 

Game:  Partridge,  squab,  woodcock,  snipe,  quail,  grouse,  roasted 
or  broiled. 

Meats,  especially  beef  and  mutton,  should  predominate.  Gelatin 
may  be  used,  but  it  is  not  very  nutritious.  It  should  be  combined 
with  meal  or  meat  preparations,  or  with  eggs  and  milk. 

Entrees:     Sweetbreads. 

Fats  and  oils  (as  much  as  can  be  digested) :  Good  fresh  butter, 
olive  oil  on  lettuce  or  raw  tomatoes,  cod-liver  oil,  the  fat  of  beef  or 
mutton  (if  it  "agrees"),  cream  (on  everything  with  which  it  can 
be  appropriately  eaten),  a  little  fat  bacon.  Pancreatin  or  pancreatic 
emulsions  will  aid  the  digestibility  of  fats. 

Vegetables:  Baked  potatoes,  tomatoes  stewed  or  raw,  very  young 
green  peas,  string  beans,  spinach,  celery  (stewed),  onions,  asparagus, 
lettuce,  cauliflower,  young  beets. 


512  DIET   IN  INFECTIOUS  DISEASES 

All  vegetables  to  be  eaten  in  moderation. 

Cereals:  Whole-meal  bread,  wheaten  or  rye,  only  if  stale  or 
toasted,  zwieback,  rusk,  milk  toast,  cream  toast,  crackers,  malted  bread 
and  biscuit,  rice  in  any  form,  puffed  rice  (p.  184)  cornmeal  "  mush," 
hominy,  farina,  cracked  wheat,  wheaten  grits,  oatmeal,  macaroni  and 
spaghetti. 

Some  authors  recommend  lentil  flour,  on  the  ground  that  it  con- 
tains both  iron  and  phosphorus.  Oatmeal  contains  considerable  fatty 
matter,  and  maize  has  still  more.  All  cereals  are  to  be  eaten 
sparingly. 

Fruits:  Apples,  baked  or  stewed,  oranges,  shaddock,  grapes,  pears, 
peaches,  plums,  strawberries,  blackberries,  olives,  prunes. 

Desserts:  Wine- jelly,  lemon,  or  coffee  jelly,  custard,  blanc- 
mange, rice  pudding,  bread  pudding,  junket  and  cream,  Bavarian 
cream,  "  floating  island,"  sponge  cake,  sago,  or  tapioca  pudding. 

Avoid  fried  foods,  rich  sauces,  pastry,  cakes,  hot  breads,  ragouts, 
beans,  carrots,  turnips,  cabbage,  confectionery,  puddings,  dried  foods, 
salt  fish  or  meats  (except  as  specified  above),  potted  meats  and  in 
general  twice-cooked  or  "made  over"  dishes. 

Beverages  Allowed. —  Water,  tea,  coffee,  cocoa,  milk,  koumiss,  zoo- 
lak,  buttermilk,  eggnog,  milk  punch,  lemonade  or  orangeade,  Vichy 
or  other  aerated  water,  non-fermented  grape  juice,  malt  extracts. 

Alcohol:  Beer,  ale,  porter,  wines,  liquors,  are  permissible  only 
if  needful  for  special  symptoms  —  that  is,  if  desirable  for  food  or  to 
aid  digestion  and  promote  exercise. 

The  late  H.  P.  Loomis  gave  the  following  useful  sample  diet,  with 
the  appropriate  intervals  for  taking  food.  A  glass  or  two  of  milk  may 
be  added  at  night  with  advantage : 

"  On  Awakening. —  Eight  ounces  of  equal  parts  of  hot  milk  and 
Seltzer,  taken  slowly  through  half  an  hour. 

"  Breakfast, —  Oatmeal  or  cracked  wheat,  with  a  little  sugar  and 
an  abundance  of  cream,  rare  steak,  or  loin  chops,  with  fat;  soft- 
boiled  or  poached  egg,  cream  toast,  half  pint  of  milk,  small  cup  of 
coffee. 

"  Lunch,  10  A.  M. —  Half  pint  of  milk  or  small  teacup  of  squeezed 
beef  juice,  with  stale  bread.  12,  noon:  Eest  or  sleep. 

"  Midday  Meal,  12.30. — Fish,  broiled  or  stewed  chicken,  scraped- 
mcat  ball,  stale  bread,  and  plenty  of  butter,  baked  applet  and  cream, 
two  glasses  of  milk. 

"Lunch,  4  P.  M. —  A  bottle  of  koumiss,  raw  scraped-beef  sandwich, 
or  goblet  of  milk.  5.30  p.  M.  :  Eest  or  sleep. 

"Dinner,  6  p.  M. —  Substantial  meat  or  fish  soup,  rare  roast  beef 


TUBEECULOSIS  513 

or  mutton,  game,  a  slice  of  stale  bread,  spinach,  cauliflower,  or  other 
fresh  vegetables  in  season  (sparingly)." 

At  9  P.  M.  half  an  ounce  of  cod-liver  oil  should  be  taken,  or  an 
ounce  of  peptonized  cod-liver  oil  and  milk.  A  2  A.  M.,  or  there- 
about, if  the  patient  awakens,  a  glass  of  milk,  zoolak,  or  diluted 
cream  should  be  drunk,  or  a  scraped-beef  sandwich  may  be  eaten. 

Diet  in  Advanced  Cases 

It  not  rarely  happens  that  patients  who  have  suffered  much  from 
indigestion  in  the  earlier  stages  of  phthisis  finally  reach  a  condition 
in  which,  although  greatly  emaciated  and  prostrated,  they  seem  able 
to  eat  and  digest  a  much  larger  variety  and  quantity  of  food  than 
before.  As  these  cases  are  utterly  hopeless,  it  is  often  best  to  let 
such  patients  select  their  own  diet,  provided  only  that  it  is  nutritious 
and  of  quality  which  does  not  excite  cough  or  diarrhoea. 

If  the  bowels  are  not  too  loose,  fresh  fruit,  especially  oranges,  may 
be  allowed,  and  prove  refreshing. 

In  very  advanced  cases,  and  in  all  cases  during  acute  exacerba- 
tions of  severity,  with  marked  prostration,  the  patient  should  take 
food  every  two  or  three  hours,  and  the  intervals  of  feeding  should 
never  be  longer.  A  diet  consisting  very  largely  of  milk  or  milk  and 
cream  is  best,  to  which  broths  and  pancreatinized  meat  preparations, 
albumoses,  and  egg  albumen  may  be  added. 

Milk  Diet. —  Milk  is  a  food  which  is  especially  adapted  for  con- 
sumptives, many  of  whom  do  best  when  living  upon  it  almost  ex- 
clusively, while  others  should  drink  it  freely  in  connection  with 
other  nourishment.  It  is  fattening,  is  assimilated  without  overtax- 
ing the  digestive  organs,  and  taken  hot,  either  alone  or  with  an  equal 
part  of  Vichy,  it  is  soothing  to  the  throat  and  ameliorates  the 
cough. 

Patients  having  advanced  tuberculosis  living  upon  full  milk  diet 
should  take  between  two  and  a  half  and  four  quarts  a  day,  but  not 
over  eight  ounces  at  once.  It  should  be  sipped,  and  not  drunk  hastily, 
for  it  then  will  coagulate  by  slow  degrees  in  the  stomach  and  not 
form  large  indigestible  curds.  This  should  be  insisted  upon  and 
ten  minutes  should  be  occupied  in  drinking  half  a  pint.  If  the 
milk  disagrees  at  first  it  may  be  modified  in  any  one  of  the  ways 
suggested  on  p.  86. 

In  this  country  cow's  milk  is  preferred,  but  elsewhere  the  milk 

of  other  animals  serves  equally  well.     Goat's  milk,  drunk  largely  in 

Switzerland,  contains  more  salts  of  lime  and  is  good  for  cases  of 

tubercular  diarrhoea,  and  sometimes  ass's  or  mare's  milk  proves  more 

35 


514  DIET   IN   INFECTIOUS  DISEASES 

digestible.  The  latter  varieties  are  principally  used  in  Eussia. 
Koumiss,  zoolak,  or  kefir  may  be  preferred. 

Lebert's  Milk  Cure  (from  Bauer). — "  Lebert  directs  the  patient 
to  drink  slowly  three  hundred  to  five  hundred  grams  (^-1  pint)  of 
milk  every  morning  and  evening  between  five  and  six  o'clock,  fasting. 
He  prefers  it  freshly  drawn  from  the  cow,  and  if,  in  consequence  of 
having  stood  for  some  time,  a  separation  of  the  cream  has  already 
begun,  recommends  it  to  be  skimmed  off. 

"  During  the  continuance  of  the  milk  treatment  the  patient  is 
allowed  a  substantial  dinner,  at  least  of  soup,  roast  meat,  young 
vegetables,  stewed  fruit,  etc.,  and  a  little  beer  or  wine.  At  the  dis- 
cretion of  the  physician  a  proper  breakfast  may  be  taken  an  hour 
after  the  morning's  milk  of  a  cup  of  tea  with  plenty  of  milk  and 
biscuits  and,  perhaps,  one  or  two  light-boiled  eggs,  and  again  in 
the  evening  a  good  soup,  as  well  as,  when  possible  (i.  e.,  in  the  case 
of  non-febrile  patients),  more  roast  meat.  If  milk  is  well  borne, 
the  regular  breakfast  and  supper  may  be  supplemented  by  further 
doses  of  one  hundred  to  two  hundred  grams  of  milk." 

Whey  may  be  drunk  instead  of  milk.  With  some  patients  cream 
diluted  with  an  equal  bulk  of  hot  water  agrees  better  than  milk. 
The  taste,  if  complained  of,  may  be  modified  by  a  very  little  tea 
or  coffee,  or  salt  or  sugar.  Yeo  sometimes  adds  a  teaspoonful  of 
rum  or  brandy  or  aromatic  spirit  of  ammonia.  Some  patients  can 
take  a  pint  of  cream  besides  two  quarts  of  milk  per  diem  with  profit. 

Suralimentation 

Suralimentation,  called  also  "  superalimentation,"  or  "  forced  feed- 
ing," is  based  upon  the  theory  that  the  best  method  to  combat  the 
symptoms  of  phthisis  is  by  forcing  the  patient  to  take  all  the  food 
which  he  can  possibly  digest.  More  food  is  needed  than  in  health 
to  counterbalance  rapid  tissue  waste.  The  appetite  is  not  always  a 
reliable  indication  of  the  strength  of  the  digestive  organs,  and, 
acting  upon  this  fact,  Debove  introduced  the  plan  of  feeding  by  means 
of  the  cesophageal  tube.  It  is  only  necessary  to  use  this  method 
when  a  patient  loses  all  appetite,  or  acquires  a  positive  disgust  for 
food,  and  rapidly  emaciates  in  consequence.  The  tube  is  employed 
in  the  manner  described  for  feeding  cases  of  insanity  (see  Melan- 
cholia), and  any  form  of  desirable  fluid  food  is  introduced  through 
it.  It  is  sometimes  only  necessary  to  pass  the  tube  into  the 
oesophagus,  and  the  first  few  times  that  it  is  used  it  may  be  well 
to  brush  the  pharynx  with  a  four-per-cent  solution  of  cocaine.  The 
meals  may  be  given  three  or  four  times  a  day,  or  a  patient  whose  appe- 


TUBERCULOSIS  515 

tite  is  not  wholly  lost,  but  is  inadequate,  may  prefer  to  eat  part  of 
his  food  himself  and  have  other  meals  furnished  through  the  tube. 

In  a  recent  inquiry  among  65  well-known  sanitoria  for  consump- 
tives, both  foreign  and  domestic,  Prof.  Irving  Fisher  found  that  28 
employ  forced  feeding,  20  did  not,  and  the  others  had  varying  systems. 

The  following  are  the  foods  most  suitable  for  tube  feeding:  1. 
Milk  and  its  preparations;  cream.  2.  Eaw  eggs,  eggnog.  3.  Meat 
extracts,  beef  juice,  beef  meal  or  powder.  -1.  Leguminous  purees  and 
cereals,  thoroughly  cooked  and  made  fluid  by  predigestion  with  malt 
extract.  A  quart  of  food  may  be  given  at  a  time.  If  gastric  catarrh 
is  present  the  gavage  should  be  preceded  by  lavage. 

Debove,  speaking  of  his  method,  says :  "  A  patient  who  has  no 
appetite,  or  who  has  a  decided  disgust  for  all  food,  will  digest  per- 
fectly a  large  meal  introduced  by  the  tube,  and  even  at  the  end  of 
a  certain  time  will  recover  appetite." 

His  method  is  first  to  wash  out  the  stomach  with  cold  water,  and 
then  pour  in  through  the  tube  a  liter  of  milk,  one  hundred  grams 
of  fine  meat  powder,  and  an  egg. 

He  adds  that  with  suralimentation  night  sweats,  cough,  and  ex- 
pectoration are  all  reduced  or  disappear  completely,  while  there  is 
considerable  gain  in  weight  and  strength  and  improvement  in  the 
physical  signs  in  the  chest. 

Suralimentation  also  may  be  conducted  without  the  stomach  tube 
in  patients  who  are  able  and  willing  to  eat.  They  may  be  given  five 
or  six  meals  a  day.  This  applies  to  patients  who  are  not  having 
severe  hectic  fever,  and  in  whom  gastric  catarrh  is  not  a  prominent 
symptom.  Should  vomiting  occur  during  the  treatment,  it  will  be 
necessary  to  suspend  it  until  the  stomach  is  again  in  order.  As  a 
rule,  in  such  instances  it  is  better  to  discontinue  medicines  than 
food,  if  both  are  being  taken.  The  presence  of  moderate  fever  — 
one  or  two  degrees'  increase  of  temperature  —  is  not  in  itself  alone 
a  contraindication  for  forced  feeding,  or  for  keeping  the  patient  con- 
fined to  bed.  The  gain  of  appetite  which  often  accompanies  removal 
to  a  favorable  climate  may  be  utilized  to  promote  forced  feeding. 

Diets  for  Forced  Feeding. —  The  following  diet  recommended  by 
Solis-Cohen  serves  as  a  good  illustration  of  the  proper  regimen  in 
the  cases  under  discussion: 

"  The  patient  is  to  take  a  pint  of  hot  water  in  the  early  morning 
to  stimulate  the  stomach  and  cleanse  it  of  mucus  accumulated  over- 
night. 

"  A  half  hour  after  the  morning  bath,  milk  punch  and  beef  meal 
or  peptonoids. 


516  DIET  IN  INFECTIOUS  DISEASES 

"Breakfast,  a  half  hour  later,  consisting  of  rare  steak  or  chop, 
eggs,  sliced  tomatoes,  bread  With  plenty  of  butter,  or  cracked  wheat 
and  cream.  In  two  hours,  koumiss  or  soup,  milk,  bread  and  butter, 
celery  salad,  broth,  and  peptonoids. 

"  Dinner,  1  P.  M. —  Bouillon,  rare  beef,  greens,  Burgundy,  or  beer, 
fruits. 

"3  or  4  p.  M. —  Koumiss,  cream,  or  milk  punch,  peptonoids,  malt 
extract. 

"  7  P.  M. —  Supper,  like  breakfast. 

"  9  or  10  P.  M. —  Cream  and  cocoa  or  coca  wine,  milk,  and  pep- 
tonoids." 

The  patient  should  keep  milk,  or  peptonoids,  or  some  nutritious 
beverage  by  the  bedside  to  be  drunk  if  he  awakens  in  the  middle 
of  the  night. 

Weber  in  his  Croonian  Lectures  outlined  the  following  diet: 

"  7  A.  M. —  While  still  in  bed,  a  cup  of  milk  with  a  dessertspoon- 
ful of  Cognac  or  lime  water,  or  a  cup  of  tea  or  cocoa,  with  bread 
and  butter. 

"  8.30  to  9  A.  M. —  After  dressing,  milk  and  tea  or  coffee,  bread 
and  butter,  fish,  ham,  or  bacon. 

"11  A.  M. —  Milk,  koumiss,  or  broth,  or  a  sandwich  and  glass  of 
wine. 

"  1  to  1.30  P.  M. —  A  substantial  meal  of  meat,  poultry,  fish  or 
game,  fresh  vegetables,  a  light  pudding,  fruit  and  a  glass  of  wine. 

"4  P.  M. —  Milk  or  koumiss,  tea  or  coffee,  with  bread  and  butter 
or  biscuit. 

"  7  P.  M. —  Another  meal  like  that  at  1  p.  M. 

"  9.30  to  10  P.  M. —  A  cup  of  milk,  bread  and  milk,  or  milk  or 
cream  and  farinaceous  food,  such  as  Hart's,  Liebig's,  Nestle's,  or 
Mellin's." 

Both  these  diets  include  an  unnecessary  and  often  undesirable  quan- 
tity of  alcoholic  beverages. 

The  question  may  properly  be  asked  whether  it  is  not  possible 
to  overfeed  patients  in  this  manner?  This  will  happen  when  the 
increase  in  body  weight  exceeds  the  breathing  capacity  of  the  lungs 
—  in  other  words,  when  the  facilities  for  oxygen  supply  are  dispro- 
portionate to  the  bulk  of  tissue  to  be  supplied.  The  symptoms  will 
be  a  coated  tongue  with  dyspepsia  and  biliousness,  increased  pulse 
frequence,  and  possibly  increased  dyspnoea  on  exertion,  all  occur- 
ring without  extension  of  the  local  physical  signs.  The  food  should 
then  be  reduced  in  amount.  Both  fluids  and  solids  are  to  be  re- 
stricted, and  fish  may  replace  meat  temporarily. 


TUBERCULOSIS  517 

Aids  to  Dietetic  Treatment 

It  is  not  within  the  scope  of  this  work  to  discuss  the  details  of 
general  hygiene  of  the  tuberculous,  but  they  should  at  least  be  men- 
tioned as  important  adjuncts  to  dietetic  treatment.  In  those  cases 
especially  in  which  forced  feeding  is  recommended  it  is  desirable  to 
promote  oxidation  in  every  way.  Patients  should  live  in  the  open  air 
all  they  can,  sleep  outdoors  or  with  the  windows  wide  open,  and,  if  pos- 
sible, go  to  a  climate  which  enables  them  to  remain  outdoors  both  day 
and  night.  They  should  wear  flannel  undergarments,  but  avoid 
dressing  too  warmly,  and  keep  the  feet  warm  and  dry.  Habits  of 
moderate  exercise,  instruction  in  proper  methods  of  breathing, 
cold  bathing,  massage,  and  reasonable  mental  diversion  and  good 
cheer  are  all  useful  factors  in  improving  the  digestion  and  assimila- 
tion of  food.  Worry  and  nervous  strain  of  every  kind  should  be 
avoided. 

Such  medicines  as  may  from  time  to  time  be  required  for  emer- 
gencies will  be  absorbed  much  better  if  the  stomach  has  not  been 
kept  long  in  a  state  of  dyspeptic  irritability.  In  patients  with  con- 
stipation appetite  and  digestion  will  be  improved  by  catharsis. 

Diet  "  Cures  "  for  Phthisis 

Many  special  forms  of  dietetic  treatment  have  been  devised  and 
extensively  practiced  for  the  cure  of  pulmonary  tuberculosis.  The 
details  of  these  "  cures  "  are  elsewhere  described.  The  principal  ones 
are  known  as  the  "  Milk  Cure,"  the  "  Whey  Cure,"  the  "  Koumiss 
Cure,"  practiced  chiefly  on  the  steppes  of  southeastern  Eussia,  and 
the  "  Grape  Cure,"  which  is  conducted  at  Meran,  Montreux,  and 
elsewhere  in  the  months  of  September  and  October.  Aside  from 
climatic  influences  and  the  effects  of  good  hygienic  surroundings, 
their  benefits  are  attributable  mainly  to  the  fact  that  the  patient  is 
encouraged  to  take  a  large  quantity  of  easily  digestible  food  and  live 
constantly  in  the  open  air. 

All  manner  of  absurd  foods,  such  as  fish  roes  in  Germany  and 
snails  in  the  south  of  France,  have  achieved  fame  with  credulous 
persons  as  possessing  specific  virtues  in  the  cure  of  phthisis.  It 
should  be  as  much  the  duty  of  the  physician  to  protect  them  .from 
the  chagrin,  disappointments,  and  expense  of  following  dietetic  illu- 
sions as  to  encourage  them .  in  every  reasonable  effort  for  improve- 
ment. Beyond  the  requirement  of  a  good,  nourishing,  easily  diges- 
tible diet,  there  is  no  specific  food  "  cure  "  for  tuberculosis,  as  there 
is  no  medicinal  cure. 


518  DIET  IN  DISEASES  OF  RESPIKATORY  SYSTEM 

SYPHILIS 

It  has  been  established  that  syphilis,  especially  in  the  tertiary  stage, 
yields  much  more  satisfactorily  to  the  mercury  and  potassium  iodide 
treatment  when  the  patient's  nutrition  is  maintained  at  a  very  high 
standard.  A  generous  mixed  diet  is  therefore  recommended,  with- 
out other  restriction  than  that  made  dishes,  fancy  dishes,  desserts, 
pastry,  confectionery,  etc.,  should  not  be  eaten  to  the  exclusion  of 
good  nourishing  bread,  meat  and  potatoes,  etc. 

In  greatly  debilitated  patients  no  satisfactory  results  from  me- 
dicinal treatment  may  be  obtained  until  forced  feeding  is  instituted, 
as  described  on  page  515. 


In  children  who  are  subject  to  spasmodic  croup  the  attacks  are 
often  precipitated  by  dyspepsia  caused  by  overfeeding  and  nursing, 
by  improper  food,  or  by  constipation.  The  diet  therefore  should 
be  regulated  according  to  the  rules  formulated  under  the  heading 
Infant  Feeding.  Night  feeding  especially  should  be  much  restricted 
after  the  first  month  of  life.  This  usually  may  be  done  after 
two  or  three  trials.  If  the  infant  awakens  crying  at  night  it 
may  be  offered  a  little  cool  water,  and  may  presently  drop  asleep. 
Up  to  the  fourth  month  six  meals  a  day,  three  hours  apart,  are  all 
that  are  allowed,  and  from  that  time  on  until  the  second  year  five 
meals  should  suffice. 

Between  the  attacks  the  milk  should  be  lessened  in  quantity,  and 
so  modified  as  to  insure  more  perfect  digestion.  Children  over  six 
months  of  age  should  be  given  from  one  to  three  tablespoonfuls  of 
pressed  beef  juice  in  a  day.  Older  children  should  take  a  fluid 
diet  of  meat  broths,  milk,  and  egg  albumen,  solid  food  being  withheld 
until  the  seizures  abate.  Cod-liver  oil  should  be  given  in  most  cases. 

TUBERCULAR  LARYNGITIS 

In  tubercular  laryngitis  intense  pain  is  excited  by  the  act  of 
deglutition.  Nutritious  but  non-irritating  food  is  therefore  required. 
Thick  soups  and  gruels,  purees,  cream,  beaten  raw  eggs,  scraped  rare 
beef,  raw  oysters,  junket,  custard,  beef,  chicken  or  wine  jellies,  all 
may  be  swallowed  more  readily  than  very  fluid  or  very  solid  food. 


HEMORRHAGE  OF  THE  LUNGS  519 

Strong  condiments,  vinegar,  and  salt  should  be  avoided,  for  they 
increase  the  pain.     So  also  do  very  hot  or  cold  foods. 

The  difficulty  experienced  in  deglutition  is  considerably  relieved 
by  the  method  proposed  by  Wolfenden,  which  is  to  have  the  patient 
lie  prone  on  a  lounge,  and  with  his  face  protruding  over  the  lower 
edge  he  is  to  suck  through  a  glass  tube  semifluid  food  from  a  tum- 
bler on  the  floor.  Sajous  advises  the  patient  to  lean  over  forward 
when  eating,  which,  he  says,  "  causes  the  food  to  pass  down  along 
the  pyriform  sinuses,  thus  avoiding  the  upper  portion  of  the  larynx, 
contact  with  which  causes  the  severe  pain  experienced  by  advanced 
cases  during  the  act  of  deglutition." 

HEMORRHAGE  OF  THE  LUNGS 

Hemorrhage  of  the  lungs,  or  rather  from  the  bronchial  mucous 
membrane,  when  occurring  suddenly  and  in  considerable  amount, 
greatly  reduces  the  strength,  and  naturally  alarms  the  patient  and 
excites  the  nervous  system.  Absolute  quiet  immediately  should  be 
secured  by  rest  in  bed  without  a  pillow,  so  that  the  body  may  lie 
flat,  and  the  head  and  arms  should  on  no  account  be  raised.  The 
room  should  be  kept  quiet  and  the  patient  must  not  be  allowed  to 
speak  or  to  feed  himself.  A  reliable  and  quiet  nurse  should  be 
secured  for  him,  and  he  should  be  fed  upon  a  diet  which  requires 
no  effort  in  eating.  Small  quantities  only  of  fluid  should  be  given 
at  one  time  through  a  glass  tube  or  by  a  teaspoon,  so  that  the  head 
need  not  be  raised.  If  nausea  occurs,  every  effort  should  be  made 
to  control  it,  for  the  violent  muscular  action  and  the  temporary  cir- 
culatory and  respiratory  disturbances  occasioned  by  the  act  of  vomit- 
ing might  excite  further  hemorrhage.  It  is  desirable  to  reduce  the 
blood  pressure  in  the  lungs  as  much  as  possible  in  order  to  allow 
coagulation  of  the  blood  to  occur  over  the  oozing  surface  of  the 
bronchial  mucous  membrane,  and  therefore  large  quantities  of  fluid 
should  not  be  given  at  first.  The  patient  is  usually  thirsty  from  the 
loss  of  blood  and  temporary  drying  of  secretions.  The  thirst  may 
be  relieved  by  crushed  ice  and  small  quantities  of  cold  acidulated 
drinks,  such  as  very  dilute  phosphoric  acid  or  sour  lemonade,  or 
oatmeal  water,  and  if  the  stomach  is  in  normal  condition,  plain  milk 
may  be  given  or  else  pancreatinized  milk  and  strong  beef  broth  in 
quantities  not  exceeding  two  or  three  ounces  in  as  many  hours. 

It  is  customary  to  administer  all  fluids  cold,  but  the  advantage 
of  this  is  overrated.  Warm  fluids  have  a  somewhat  more  stimulating 
effect  upon  the  heart,  probably  through  reflex  vagus  action,  and  are 


520  DIET  IN  DISEASES  OF  RESPIRATORY  SYSTEM 

more  rapidly  absorbed,  but  the  idea  sometimes  advanced  that  the 
cold  of  iced  fluids  taken  into  the  stomach  is  ever  sufficient  to  con- 
strict the  bleeding  bronchial  vessels,  even  by  supposed  reflex  action, 
does  not  appear  rational.  For  a  full  discussion  of  this  question  the 
reader  is  referred  to  experiments  reported  upon  p.  375. 

If  gastric  disorder  is  present  with  bronchial  hemorrhage,  to  fore- 
stall vomiting  it  may  be  better  to  resort  to  nutrient  enemata. 

In  cases  where  exceptionally  large  quantities  of  blood  have  been 
lost,  the  blood  pressure  may  be  reduced  greatly  and  the  danger  of 
death  from  heart  failure  may  appear  imminent.  It  then  becomes 
necessary  to  give  a  larger  quantity  of  fluid,  and  the  rules  in  regard 
to  the  dietetic  treatment  of  severe  and  sudden  hemorrhage  taking 
place  anywhere  from  the  body  should  be  observed.  Salt  and  water, 
a  teaspoonful  to  the  pint,  may  be  injected  into  the  rectum,  or  be- 
neath the  skin.  Most  cases,  however,  are  more  mild,  and  after  a 
few  hours  of  rest  and  quiet,  furthered,  perhaps,  by  the  hypodermic 
injection  of  morphine,  the  patient  will  be  able  to  retain  a  little  simple 
semisolid  food,  such  as  milk  toast,  a  beaten  egg,  junket,  etc. 

If  there  is  no  return  of  the  hemorrhage  in  a  day  or  two,  the 
diet  should  be  increased  and  anaamia  consequent  upon  the  bleeding 
treated  by  an  abundant  meat  diet  with  eggs  and  cream.  Alcoholic 
stimulants  should  be  avoided,  on  account  of  the  relation  of  blood 
pressure  to  the  bleeding. 

ACUTE  CAPILLARY  BRONCHITIS 

In  acute  capillary  bronchitis  in  infants  and  children  an  exclusive 
fluid  diet  of  the  simplest  but  most  nutritious  kind  should  be  enforced. 
In  young  infants  milk  alone,  in  older  children  milk,  meat  juice, 
meat  broths,  and  beaten  eggs  or  egg  albumen,  should  be  fed  at  least 
every  two  hours  in  such  quantities  as  the  stomach  will  bear.  It  may 
be  best  to  pancreatinize  all  food.  Very  feeble  children  will  require 
food  oftener,  and  sometimes  a  teaspoonful  only  should  be  ordered 
once  every  fifteen  or  twenty  minutes  for  a  few  hours.  If  the  child 
refuses  food  or  vomits  constantly,  a  nutrient  enema  (p.  455)  once  in 
three  or  four  hours  may  be  given. 

CHRONIC  BRONCHITIS 

The  diet  for  chronic  bronchitis  is  substantially  the  same  as  that 
recommended  for  the  earlier  stages  of  pulmonary  phthisis,  to  which 
the  reader  is  referred  (p.  511). 


ASTHMA  521 

The  cough  is  often  momentarily  relieved  by  drinking  hot  lemon- 
ade, hot  milk  and  Seltzer  or  Vichy,  and  sometimes  by  sucking  a  raw 
egg  through  a  perforated  shell. 

ASTHMA 

Asthmatic  patients  soon  find  from  experience  that  errors  in  diet 
are  liable  to  precipitate  an  attack,  and  overloading  the  stomach  or 
eating  particular  kinds  of  food,  which  are  unwholesome  or  against 
which  the  individual  possesses  idiosyncrasy,  may  excite  dyspnoea. 
Aitkin  showed  a  true  appreciation  of  the  importance  of  diet  in  this 
disease  when  he  wrote :  "  More  is  to  be  done  for  asthmatic  patients 
on  the  side  of  the  stomach  than  in  any  other  direction,"  and  "  the 
asthmatic  can  never  with  impunity  eat  and  drink  as  other  people." 

Accumulation  of  large  quantities  of  undigested  and  fermenting 
food  results  in  the  production  of  gas  in  both  the  stomach  and  intes- 
tines, which  become  distended  and  by  pressure  interfere  with  the 
movements  of  the  diaphragm  and  abdominal  muscles  in  free  respira- 
tion. The  chemical  irritation  of  undigested  food  may  be  a  cause 
of  reflex  spasm  of  various  muscles,  and  may  possibly  affect  those 
of  respiration.  It  is  therefore  necessary  for  asthmatics  to  exercise 
care  in  the  selection  of  their  food  and  to  keep  the  digestive  organs 
in  as  normal  a  condition  as  possible.  All  food  which  is  constipating 
or  which  is  liable  through  fermentation  to  evolve  large  quantities  of 
gas  should  be  shunned,  and  constipation  through  autointoxication 
may  provoke  an  asthmatic  attack.  In  general,  red  meats,  fats  and 
sweets  should  be  given  up,  and  starchy  food,  if  eaten  at  all,  should  be 
thoroughly  cooked  and  slowly  masticated,  in  order  that  the  salivary 
digestion  of  it  may  be  as  complete  as  possible.  Pork,  veal,  and  cheese 
should  never  be  eaten,  and  elaborate  cooking  and  desserts  are  for- 
bidden. No  water  should  be  allowed  with  meals  or  until  at  least 
three  hours  thereafter.  A  cup  of  very  hot  water  may  be  drunk  an 
hour  before  each  meal  and  again  at  night. 

In  most  asthmatic  patients  the  attacks  are  worse  at  night,  and 
in  many  they  occur  only  at  that  time.  It  is  consequently  better  for 
them  to  take  the  principal  meal  of  the  day  at  noon  and  eat  a  light 
supper,  so  that  gastric  digestion  may  be  finished  before  retiring. 

The  following  diet  may  afford  a  general  idea  of  the  regimen  for 
somewhat  advanced  cases  when  paroxysms  are  frequent. 

Breakfast. —  Bread  and  milk  or  well-cooked  oatmeal  porridge  or 
wheaten  grits  without  sugar  (lemon  juice  may  be  added  instead). 

A  little  broiled  fresh  fish,  coffee  without  sugar. 
36 


522  DIET  IN  DISEASES  OF  RESPIRATORY  SYSTEM 

Dinner  (not  later  than  2  p.  M.). —  Chicken,  bread,  one  or  two 
green  or  succulent  vegetables,  such  as  spinach,  stewed  celery,  stewed 
or  raw  tomatoes.  Blancmange  or  custard  (not  sweetened),  or  a 
little  rice  pudding.  Fresh  fruit  in  season,  such  as  a  peach  or  baked 
apple. 

Supper  (6  p.  M.). —  A  soft-cooked  egg,  a  little  bacon,  stale  bread, 
toast,  or  zwieback,  milk,  stewed  fruit  (without  sugar). 

Patients  should  eat  moderately,  and  slowly,  and  take  their  meals 
with  punctuality. 

Among  beverages,  coffee  without  sugar  is  better  borne  than  tea. 
The  late  A.  L.  Loomis  believed  that  "  not  infrequently  a  paroxysm  of 
asthma  can  be  warded  off  by  taking  two  or  three  cups  of  strong 
coffee  immediately  upon  the  accession  of  the  first  asthmatic  symp- 
tom." 

During  an  attack  non-alcoholic  patients  may  take  a  hot  strong 
lemonade  with  whisky  or  a  hot  brandy  and  soda.  Malt  liquors  are 
forbidden. 

The  dietetic  treatment  of  the  intervals  between  paroxysms  is  im- 
portant. The  patient  should  live  principally  upon  green  vegetables, 
fresh  fruits,  fish,  eggs,  and  chicken  or  ham,  and  red  meats  should 
not  be  eaten  more  than  two  or  three  times  a  week.  Abundant  water 
should  be  drunk  between  meals. 

EMPHYSEMA 

Patients  suffering  from  emphysema  have  more  or  less  engorge- 
ment of  the  venous  circulation,  and  hence  are  liable  to  catarrh  of 
the  stomach  and  intestines.  The  dyspnoea  from  which  they  suffer 
on  exertion  is  considerably  augmented  by  flatulency,  and  their  diet 
should  be  regulated  to  prevent  this  occurrence.  In  general,  starchy 
and  saccharine  foods  are  to  be  avoided,  and  constipation  should  be 
prevented.  For  a  discussion  of  these  principles,  the  reader  is  re- 
ferred to  the  articles  upon  Gastric  Dyspepsia  and  Constipation 
(pp.  579,  639). 

The  patient  is  to  be  particularly  warned  against  too  rapid  eating 
and  overeating.  Condiments,  sauces,  fried  and  greasy  food,  and  all 
obviously  indigestible  articles,  should  be  shunned.  Fluids  should  not 
be  drunk  with  solid  food,  and  should  be  used  in  moderation.  Water 
may  be  drunk  an  hour  before  meals,  but  not  for  three  hours  after,  to 
avoid  gastric  distention.  In  the  early  stage  without  asthma  a  diet 
consisting  chiefly  of  animal  food,  meat,  fish,  milk,  cream,  eggs,  and 
good  butter,  should  be  taken.  If  dyspnoea  predominates  with  frequent 


PNEUMONIA  523 

asthmatic  attacks,  it  will  be  best  to  substitute  milk  largely  for  other 
foods,  and  in  the  later  stages,  with  a  feeble  heart  and  increasing  con- 
gestion of  the  abdominal  viscera,  the  diet  should  consist  solely  of  milk, 
eggs  and  meat  broths.  Cod-liver  oil  is  an  excellent  food  in  the  early 
stage  of  emphysema. 

PNEUMONIA 

Symptoms. —  Pneumonia  is  an  infectious  inflammatory  disease  of 
the  lungs,  accompanied  by  grave  constitutional  disturbances,  such 
as  fever  and  rapid  and  enfeebled  heart  action.  Whereas  no  known 
remedy  limits  the  disease,  it  is  exceedingly  important  to  maintain 
the  strength  of  the  patient  through  the  few  days  during  which  the 
fever  lasts,  or  until  the  crisis  by  which  it  terminates  has  been  reached. 
All  danger,  however,  is  not  then  over,  and  convalescence  in  all  cases, 
and  especially  in  aged  persons,  may  be  promoted  by  careful  dietetic 
treatment.  The  onset  of  the  disease  is  acute,  and  the  temperature  is 
usually  high,  reaching  104°  or  105°  or  more  on  the  first  day.  The 
duration  of  the  fever  varies  from  five  to  seven  or  nine  days  on  the  aver- 
age, when  it  subsides  by  a  more  or  less  sudden  fall.  The  rate  of 
respiration  is  greatly  accelerated,  with  or  without  subjective  dyspnoea. 
More  or  less  cough  accompanies  the  fever,  and  there  is  often  deli- 
rium. 

Dietetic  Treatment. —  The  indications  for  treatment  are  to  give 
a  light  diet,  which  will  not  excite  the  cough  in  swallowing  or  in- 
crease dyspnoea  by  distention  of  the  stomach,  or  augment  the  en- 
feeblement  of  the  heart  action  by  overtaxing  the  digestive  powers. 
Vomiting  especially  should  be  guarded  against,  and  if  nausea  exists, 
efforts  should  be  made  at  once  to  control  it.  It  is  not  necessary  to 
keep  the  patient  upon  a  strict  milk  diet,  but  if  milk  be  well  borne,  it 
is  advisable  to  give  nothing  else  while  the  acute  symptoms  last; 
otherwise,  whey,  meat  juice,  broths,  and  egg  albumen  may  be  allowed. 
Starchy  and  saccharine  food  should  be  withheld.  Cold  drinks  are 
both  acceptable  and  beneficial  to  the  patient,  and  water,  plain  or 
aerated,  such  as  Apollinaris  of  soda  water,  may  be  drunk  in  con- 
siderable quantity.  The  activity  of  the  kidneys  >  thus  may  be  pro- 
moted, and  the  poison  which  occasions  the  constitutional  symptoms 
of  the  disease  better  eliminated.  There  are  cases,  however,  among 
persons  with  robust  circulation  in  which  the  onset  is  very  sudden 
and  violent.  The  pulse  is  full  and  bounding,  and  the  heart  is 
greatly  overworked  by  the  effort  to  propel  a  large  volume  of  im- 
perfectly aerated  blood.  In  such  instances  the  addition  of  large 


524  DIET  IN  DISEASES  OF  RESPIRATORY  SYSTEM 

quantities  of  fluid  to  the  circulation,  besides  what  is  actually  required 
for  nutrition,  may  have  the  effect  of  still  further  straining  the  heart. 
It  is  stated  that  carbonated  waters  reduce  the  viscidity  of  the  sputum, 
which  is  very  tenacious. 

The  diet  should  be  fluid  until  defervescence  has  occurred,  with  a 
normal  temperature  and  commencing  disappearance  of  the  exudation 
—  in  fact,  it  is  well  to  prolong  the  fluid  diet  for  three  or  four  days 
after  the  temperature  has  become  normal.  In  those  cases  in  which 
resolution  is  postponed  and  the  patient  becomes  more  and  more  feeble, 
although  the  temperature  may  be  nearly  or  quite  normal,  it  may  be 
desirable  to  give  a  little  properly  prepared  solid  food  somewhat  earlier, 
and  scraped  beef,  milk  toast,  or  a  soft  cooked  egg  may  be  added  to 
the  milk  diet. 

Tympanites  is  a  most  undesirable  symptom  on  account  of  the 
increased  difficulty  in  breathing  which  it  causes.  When  present  it  is 
best  to  withhold  milk  temporarily  (as  in  tympanites  with  typhoid 
fever,  p.  477)  and  rely  upon  meat  juice,  broths,  peptonoids  and 
eggs. 

During  the  entire  period  of  convalescence  the  diet  should  be  very 
nourishing  and  of  easy  digestion;  milk  may  still  be  given,  with  other 
food,  and  after  slowly  returning  to  the  regulation  three  meals  a  day 
(see  Convalescent  Diet).  Very  feeble  patients  do  well  to  take  milk 
punch,  or  eggnog,  or  a  glass  of  wine  and  a  biscuit  three  or  four  times 
a  day  in  the  intervals  between  meals. 

In  alcoholic  subjects  who  have  been  drinking  up  to  the  time  of 
the  onset  of  the  disease  it  may  be  indispensable  to  continue  the  use 
of  alcohol,  for  the  sudden  withdrawal  of  its  stimulating  effect  on 
the  organism  may  give  rise  to  rapid  collapse.  In  aged  and  con- 
stitutionally weak  persons  it  is  also  often  indicated,  but  the 
majority  of  patients  if  given  abundant  fresh  air,  are  better 
without  it. 

The  custom  of  prescribing  other  forms  of  cardiac  stimulants,  such 
as  digitalis,  strychnine,  strophanthus,  makes  the  employment  of  ex- 
cessive doses  of  alcohol  unnecessary.  It  should  be  remembered  that 
it  is  undesirable  to  produce  toxic  symptoms  of  alcoholism  in  pneu- 
monia as  well  as  in,  any  other  disease.  So  long  as  the  pulse  is  slowed 
and  its  force  strengthened  the  use  of  alcohol  may  be  regarded  as 
beneficial :  but  if  delirium  is  increased  and  the  odor  of  whisky  or 
brandy  is  strong  in  the  breath  an  hour  or  two  after  it  has  been  given, 
it  is  an  indication  that  the  patient  is  receiving  more  than  is  desirable, 
and  the  dosage  should  be  reduced.  For  several  years  I  have  treated 
the  majority  of  my  pneumonia  cases  without  any  alcohol  whatever. 


BRONCHO-PNEUMONIA  —  PLEURISY 

BRONCHO-PNEUMONIA 

Symptoms. —  Broncho-pneumonia  is  common  at  the  extremes  of 
age,  in  the  very  old  and  very  young.  The  mortality  is  high  in  chil- 
dren under  two  years  of  age.  It  is  the  sequel  to  many  of  the  acute 
diseases  of  childhood,  and  also  is  produced  by  aspiration  of  particles 
of  food  or  fluid  which  are  drawn  through  the  larynx  to  the  bronchi 
by  inhalation  during  the  act  of  swallowing,  especially  during  de- 
lirium, and  when  the  mouth  is  dry  and  foul.  The  latter  variety, 
known  as  "  aspiration  pneumonia,"  may  occur  as  a  result  of  drawing 
seeds  or  other  hard  substances  into  the  bronchi ;  from  operations  about 
the  mouth  and  upper  air  passages  after  tracheotomy;  and  from  the 
conditions  which  impair  the  normal  sensitiveness  of  the  larynx  and 
the  reflex  action  of  the  epiglottis  and  vocal  cords,  such  as  profound 
uraemia  or  apoplectic  or  alcoholic  coma,  and  post-diphtheritic  or 
laryngeal  paralysis.  A  few  cases  have  been  produced  by  carelessness 
in  passing  an  cesophageal  catheter  into  the  larynx  and  pouring  liquid 
food  into  it. 

Dietetic  Treatment. —  Broncho-pneumonia  is  always  a  very  critical 
disease  and  the  utmost  care  is  required  in  nursing  and  feeding. 
Stimulation  may  be  required  early  in  considerable  quantity.  Hot 
milk  and  Vichy,  in  the  proportion  of  one  part  of  Vichy  to  two  of 
milk  for  older  children,  or  half-and-half  for  young  infants,  may 
have  the  effect  of  loosening  the  tenacious  mucus  and  easing  the 
cough.  If  there  is  any  tendency  to  flatulency,  aerated  waters  had 
better  be  avoided. 

When  disease  occurs  in  children  the  diet  should  be  adapted  to 
foster  the  strength  and  tax  the  digestive  organs  as  little  as  possible. 
At  first  food  should  be  given  every  two  hours,  and  predigested  milk 
is  usually  all  that  is  required.  Later  it  may  be  alternated  with  or 
supplemented  by  egg  albumen,  expressed  meat  juice,  plain  beef  or 
mutton  broths,  arrowroot,  or  other  gruels.  For  adults  the  diet  should 
be  the  same  as  in  Pneumonia  (p.  523). 

PLEURISY 

Of  the  various  forms  of  pleurisy,  those  which  are  chiefly  influ- 
enced by  diet  are  pleurisy  with  effusion  and  empyema.  In  pleurisy 
with  effusion  the  objects  to  be  attained  are  to  preserve  the  strength 
of  the  patient  and  promote  the  reabsorption  of  the  fluid  in  the 
pleural  sac.  A  diet  is  therefore  advised  which  shall  consist  of  nutri- 
tious solids  with  a  minimum  amount  of  fluid,  in  order  that  the 


526  DIET  IN  DISEASES  OF  RESPIRATORY  SYSTEM 

blood  may  become  more  dense  and  that  favorable  osmosis  may  take 
place  from  the  pleuritic  cavity  into  the  blood  vessels;  at  the  same 
time  free  action  of  the  kidneys  should  be  promoted.  To  still  further 
favor  the  absorption  of  fluid,  the  "  salt  free "  diet  may  be  tried, 
which  is  described  on  page  556. 

An  extreme  dry  diet  known  in  Germany  as  "  Schroth's  Method " 
has  been  indorsed  by  Niemeyer,  Pimser,  and  others.  The  patient  is 
fed  upon  lean  roast  veal  and  stale  rolls  (Butterbrod)  without  fluid 
of  any  kind  but  a  little  water  until  the  third  day,  when  half  a  pint 
of  red  wine  is  given.  At  the  end  of  a  week  a  pint  is  allowed.  Very 
few  patients  will  submit  to  such  treatment  in  this  country,  and  it 
certainly  is  severe.  A  reasonable  abstinence  from  fluids,  especially 
water,  is  all  that  can  be  expected.  Practically,  many  patients  are 
found  to  go  on  reabsorbing  pleuritic  exudate  while  continuing  a 
milk  or  other  fluid  diet  which  is  necessitated  by  some  complication 
in  the  digestive  system. 

Several  French  writers,  as  Serre  and  Eloy,  advocate  an  exclusive 
milk  diet,  giving  from  three  pints  to  three  quarts  daily,  to  be  sipped 
in  small  quantities  every  hour  or  two.  They  rely  upon  the  diuretic 
effect  of  the  milk,  and  give  it  in  any  form  most  agreeable  to  the  pa- 
tient. The  treatment  is  continued  for  a  week  or  more  after  the 
exudation  has  been  absorbed,  and  return  to  a  solid  diet  should  be 
gradual.  This  method  is  obviously  directly  opposed  to  the  dry  diet, 
and  possesses  no  advantages  over  it,  excepting  sometimes  in  cases  com- 
plicated by  chronic  valvular  heart  disease,  gastric  catarrh,  or  ad- 
vanced anaemia. 

If  the  pleuritic  exudate  accumulates  in  sufficient  quantity  to 
severely  embarrass  respiration  or  the  action  of  the  heart,  it  is  so 
easy  absolutely  to  withdraw  it  by  the  aspiration  needle  when  anti- 
septic precautions  are  taken  that  annoying  the  patient  by  experi- 
mental dietetics  is  hardly  justifiable,  and  I  have  found  solid  diet 
with  reasonable  restriction  to  be,  on  the  whole,  the  most  satisfactory. 
Patients  who  are  fairly  robust  will  naturally  endure  privation  of 
food  and  drink  better  than  the  feeble  and  anaemic. 

A  majority  of  cases  of  pleurisy  are  of  tubercular  origin,  and  the 
dietetic  treatment  of  incipient  cases  of  tuberculosis  is  applicable 
(see  p.  511). 

EMPYEMA 

The  dietetic  treatment  of  empyema  is  based  upon  the  need  for 
nutrition  to  supply  the  drain  on  the  system  of  the  constant  excre- 
tion of  pus,  and  fatty  food,  such  as  butter,  cod-liver  oil,  and  cream. 


DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM       527 

should  therefore  fill  a  large  portion  of  the  dietary.  The  general 
supporting  treatment  prescribed  for  the  early  stages  of  pulmonary 
tuberculosis  (p.  511)  and  septicaemia  (p.  502)  is  recommended. 

DIET  IX  DISEASES  OF  THE  CIRCULATOKY  SYSTEM  AND 

BLOOD. 

The  proper  dietetic  treatment  of  advanced  heart  disease  deserves 
careful  consideration,  for  on  it  to  a  great  extent  depends  the  pa- 
tient's comfort,  if  not  the  prolongation  of  his  life.  It  cannot  be  said 
that  the  several  conditions  of  cardiac  enlargement,  valvular  disease, 
fatty  degeneration,  etc.,  demand  different  forms  of  treatment  per 
se,  but  there  are  certain  general  principles  which  should  be  ob- 
served in  any  case  when  particular  symptoms  arise.  The  dietetics 
of  cardiac  diseases  may,  accordingly,  conveniently  be  reviewed 
together. 

Pathological  Physiology. —  The  general  conditions  involved  are 
largely  physical,  or  rather  mechanical  —  perhaps  more  so  than  in  any 
other  form  of  disease. 

1.  The  heart  may  be  regarded  as  a  pump  whose  action  is  impaired 
by  more  or  less  weakness  of  its  walls,  or  leakage  or  obstruction  of 
its  valves,  or  which  is  overworked  by  the  imposition  of  increased  re- 
sistance. 

2.  The  balance  of  blood  pressure  in  the  vessels  is  usually  disturbed 
and  the  rate  of  blood  flow  altered. 

3.  As  the  disproportion  increases   between  the   driving  force  or 
the  resistance  of  the  vessels  and  the  volume  of  the  fluid  to  be  pro- 
pelled, there  is  leakage  of  serum  in  various  places,  producing  dropsies 
or  general  anasarca.     Or  these  conditions  may  result  from  a  diminu- 
tion in  the  vitality  of  the  peripheral  blood  vessels  or  change  in  the 
composition  of  the  blood  itself. 

4.  The  rate  of  absorption  of  the  materia  alimentaria  by  osmosis 
depends  as  much  upon  the  activity  of  the  blood  and  lymphatic  cir- 
culation—  i.  e.,  upon  the  rapidity  of  renewal  of  the  layer  of  blood 
in  the  capillaries  of  the  absorbing  surface  —  as  upon  the  density  and 
composition  of  the  blood,  the  action  of  individual  cells,  or  any  other 
factor.     A  feebly  beating  heart  or  an  obstructed  vascular  or  lymphatic 
system  promptly  checks  absorption.     Moreover,  the  reabsorption  of 
transuded    serum   depends   upon   reversal   of   the   conditions   which 
originally  caused  it. 

5.  The  elimination  of  waste  and  the  various  processes  of  secretion 
depend  upon  almost   identical   physical  or   physiological  conditions 


528       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

with  absorption,  and  while  not  due  merely  to  filtration,  are  never- 
theless controlled  promptly  by  alterations  in  vascular  pressure  and 
the  velocity  of  the  blood-current. 

Bearing  in  mind  these  elementary  principles,  the  first  question 
which  arises  in  the  dietetic  treatment  of  advanced  cardiac  disease 
concerns  the  administration  of  fluids. 

Fluids. —  An  additional  pint  of  fluid  beyond  the  needs  of  the  sys- 
tem may  be  sufficient  to  overtax  the  heart,  alter  the  balance  of  blood 
pressure,  disturb  a  temporary  compensation,  and  precipitate  anasarca, 
renal  congestion,  pulmonary  oedema,  or  other  symptoms.  On  the 
other  hand,  with  too  little  fluid  the  blood  pressure  may  fall  to  a 
dangerous  degree  or  there  may  not  be  water  enough  in  the  vascular 
system  to  maintain  the  free  diuretic  action  which  is  so  desirable. 
It  is  a  well-known  physiological  fact  that  the  heart,  like  any  other 
muscle,  does  better  work  if  it  has  reasonable  resistance  to  overcome. 
Such  are  the  problems,  briefly  stated,  which  must  be  met  by  the  com- 
parison from  day  to  day  of  the  amount  and  quality  of  the  urine, 
the  degree  of  arterial  tension,  the  force  of  the  heart  beat,  and  the 
possible  presence  of  oedema.  Each  case  must  be  studied  independ- 
ently and  variations  in  the  quality  of  the  pulse  and  of  arterial 
pressure  should  be  regulated  as  far  as  possible,  by  observing  the 
effect  of  the  ingestion  of  fluids,  and  comparing  the  output  in  the 
urine. 

Dietetic  Treatment. —  It  is  difficult  to  formulate  any  but  the  most 
general  rules  for  the  dietetic  treatment  of  chronic  valvular  disease 
of  the  heart.  These  cases  often  extend  through  a  period  of  many 
years,  and  the  variety  of  secondary  symptoms  which  may  appear  is 
great.  The  forms  of  valvular  disease  which  are  most  likely  to  result 
in  disturbances  of  digestion  are  those  in  which  obstructed  venous 
circulation  results  in  local  engorgement  of  the  abdominal  viscera, 
producing  nausea,  vomiting,  and  great  distaste  for  food.  Constipa- 
tion and  more  or  less  chronic  gastric  and  intestinal  catarrh  may  be 
among  the  symptoms.  The  hypostatic  congestion  of  the  liver  re- 
tards the  activity  of  that  organ,  and  the  ingredients  of  the  food  which 
are  brought  to  it  by  the  portal  system  are  no  longer  properly 
elaborated,  so  that  general  nutrition  and  assimilation  suffer  in  con- 
sequence. A  depleting  diet  is,  therefore,  sometimes  to  be  recom- 
mended, and  concentrated  food  is  required  to  prevent  overburdening 
the  circulation.  If  gastric  catarrh  necessitates  the  use  of  fluid  food, 
such  as  milk  and  soups  or  broths,  the  quantity  of  beverages  taken  in 
addition  si  ion  Id  bo  restricted  considerably.  When  acute  attacks  of 
indigestion  supervene  in  the  course  of  chronic  valvular  disease,  the 


DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM       529 

bowels  should  be  kept  thoroughly  open,  and  a  diet  of  milk,  beaten 
eggs,  and  broths,  taken  once  in  three  hours,  should  be  prescribed  for 
a  few  days,  after  which  boiled  fish,  broiled  chicken,  scraped  beef,  beef- 
steak, or  rare  roast  beef  may  be  added.  Fats,  farinaceous  foods, 
and  sugars  should  not  be  allowed,  owing  to  their  tendency  to  pro- 
duce flatulency  and  intensify  existing  symptoms.  The  use  of  alco- 
holic stimulation  may  at  times  become  necessary,  and  whisky  diluted 
in  some  non-effervescing  water  is  perhaps  the  best.  Beer  should 
be  avoided  particularly,  and  recommendation  of  the  regular  use  of 
stimulants,  in  this  as  in  other  forms  of  chronic  disease,  should  be 
made  with  great  caution  lest  the  alcoholic  habit  be  acquired  and  be- 
come permanent.  Patients  with  sudden  cardiac  dilatation,  such  as 
sometimes  occurs  during  convalescence  from  typhoid  fever,  need  to 
return  to  a  milk  diet. 

When  acute  symptoms  of  palpitation,  dyspnoea,  etc.,  develop,  the 
patient  should  never  eat  very  much  food  at  one  time,  and  especially 
should  not  drink  too  much  fluid  at  once.  Fluid  quickly  taken  into 
an  empty  stomach  is  promptly  absorbed,  whereas  the  same  quantity 
sipped  slowly  may  not  overtax  the  heart.  It  is  better  to  take  four 
or  five  meals  a  day,  if  necessary,  and  eat  only  small  quantities.  A 
large  meal  always  distends  the  stomach  considerably  for  several 
hours,  causing  this  organ  to  crowd  against  the  diaphragm  and  dis- 
place somewhat  the  heart,  which  lies  upon  it,  and  diminishing  the 
vertical  diameter  of  the  chest.  The  heart  may  become  irritated  by 
the  mechanical  pressure  to  which  it  is  subjected  by  a  moderate 
degree  of  displacement,  and  it  is  indirectly  affected  by  the  greater 
difficulty  of  breathing,  as  well  as  by  reflex  irritation  from  the  dis- 
ordered stomach.  All  food  which  is  liable  to  ferment  in  the  stomach, 
such  as  sugar  and  indigestible  starches  and  fats,  should  be  avoided. 
Gastric  catarrh  is  readily  initiated  or  aggravated  by  coarse  or  fer- 
menting food.  On  this  account  also  the  use  of  strong  alcohol  should 
be  forbidden  except  in  the  case  of  aged  and  feeble  persons,  to  whom 
light  wine  or  diluted  spirits  may  be  given.  The  regular  use  of  to- 
bacco should  be  prohibited,  and  tea  and  coffee,  if  permissible,  are 
to  be  taken  only  in  very  dilute  form.  The  tendency  to  constipa- 
tion may  be  overcome  by  attention  to  diet,  and  a  moderate  portion 
of  fruit,  such  as  baked  or  stewed  apples,  stewed  prunes,  stewed 
peaches,  pineapple  juice,  oranges  or  grape  fruit,  may  be  allowed  be- 
tween meals. 

When  the  terminal  stage  of  valvular  heart  disease  results  in  drop- 
sies or  general  anasarca,  the  salt-free  diet  recommended  for  pleurisy 
(p.  525)  has  sometimes  proved  beneficial. 


530       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

CARDIAC  VALVULAR  DISEASE  IN  CHILDREN 

Children  who  have  chronic  valvular  disease  or  enlargement  of  the 
heart,  but  who  are  not  confined  strictly  to  bed,  should  be  supervised 
closely  in  regard  to  their  habits  of  eating.  They  should  eat  slowly  and 
moderately,  and  have  their  meals  at  regular  intervals,  taking  the  prin- 
cipal meal  at  noon,  and  a  light  supper  two  hours  before  bedtime.  In 
general,  animal  food  is  better  for  them  than  vegetable,  but  they  may  eat 
the  lighter  fresh  vegetables,  such  as  spinach,  tomatoes,  string  beans,  or 
stewed  celery  in  season,  and  sometimes  a  little  roast  or  mashed  potato. 
Eice  and  macaroni  may  be  given.  Bread  should  be  eaten  only  stale  or 
toasted.  Sweets  should  not  be  allowed,  except  very  rarely,  when  a 
taste  of  jam  or  preserves  may  be  given.  Such  substances  are  apt  to 
cause  flatulency  and  palpitation,  if  not  more  serious  disturbances,  and 
everything  depends  upon  saving  the  heart  from  excitation  or  strain. 
All  food  should  be  very  simply  cooked,  and  too  great  variety  is  harm- 
ful. 

In  acute  endocarditis  it  is  very  important  to  avoid  all  food  likely 
to  cause  dyspepsia.  Eaw  eggs  with  broths,  and  chiefly  milk  and 
custards  should  be  prescribed,  and  if  the  stomach  is  weak  and  irritable, 
a  part  of  the  nutriment  may  be  given  per  rectum  (p.  455). 

THE  SENILE  HEART 

In  persons  past  middle  life  the  heart  may  become  enfeebled  from 
a  variety  of  causes  independent  of  inflammatory  conditions  or  valv- 
ular lesions.  Fatty  degeneration  is  a  common  cause  of  such  weak- 
ness, and  in  other  cases  the  heart  muscle  may  gradually  lose  its 
normal  strength  and  "  tone "  from  strain,  or  a  disturbance  of  bal- 
ance between  its  power  and  the  peripheral  resistance  to  be  overcome. 
In  the  aged  the  arterial  walls  become  less  and  less  resilient,  if  not 
actually  rigid,  from  fibrosis  or  calcareous  deposit,  and,  moreover, 
the  heart  suffers  no  less  than  other  organs  from  impaired  nutrition. 
In  such  cases  the  prolongation  of  the  patient's  life  as  well  as  the 
maintenance  of  his  comfort  may  be  fostered  by  attention  to  dietetics. 

A  weak  heart  implies  impaired  circulation  in  the  gastric  vessels, 
and  hence  the  gastric  juice  becomes  poor  in  quality  and  lessened  in 
quantity.  Digestion  is  consequently  retarded,  and  absorption  of 
food  products  is  less  active  than  it  should  be.  The  heart  and  the 
stomach  being  both  supplied  by  branches  of  the  vagus  nerve,  it  is 
easy  to  understand  how  gastric  irritation,  caused  by  products  of 
malfermentation,  organic  acids,  accumulated  undigested  food,  or 


THE  SENILE  HEART  531 

gaseous  distentlon,  may  affect  the  heart  through  reflex  action.  Me- 
chanically, too,  a  stomach  distended  by  gas  presses  upon  and  irritates 
the  heart.  Balfour  (The  Senile  Heart)  says:  "If  the  heart  is 
weak  the  discomfort  induced  by  such  irregularities  is  after  mid- 
dle life  more  apt  to  be  felt  in  connection  with  that  organ  than  in 
the  stomach  itself."  The  results  are  intermission  in  the  pulse  rate, 
unevenness  in  force  and  frequency  of  the  heart  beat,  its  "  fluttering  " 
action,  and  sensations  of  palpitation,  pracordial  distress,  fullness  or 
constriction,  and  dyspnoea.  In  order  to  avoid  these  symptoms  as 
far  as  possible,  the  patient  should  have  his  diet  carefully  supervised. 
A  sufficient  interval  —  fully  five  hours  —  should  elapse  for  the  com- 
plete digestion  of  one  meal  before  a  second  is  taken,  and  because 
the  gastric  juice  is  feeble  it  is  best  not  to  allow  more  than  four 
or  five  ounces  of  fluid  of  any  kind  to  be  taken  with  the  meals.  While 
sufficient  variety  of  food  may  be  allowed  to  maintain  a  fair  appetite, 
it  should  never  be  so  great  as  to  entice  the  patient  to  eat  too  freely. 

Balfour  summarizes  excellent  rules  for  dieting  to  be  followed"  by 
patients  whose  cardiac  action  is  enfeebled  by  any  cause,  but  espe- 
cially for  the  condition  described  as  "  the  senile  heart." 

BALFOUR 'S  RULES  FOR  DIETING  FOR  WEAK  HEARTS 

"  1.  There  must  never  be  less  than  five-hour  intervals  between 
meals.  2.  No  solid  food  is  ever  to  be  taken  between  meals.  3.  All 
those  with  weak  hearts  should  have  their  principal  meal  in  the  mid- 
dle of  the  day.  4.  All  those  with  weak  hearts  should  have  their  food 
as  dry  as  possible." 

A  good  typical  menu  is  given  by  the  writer  above  quoted : 

BALFOUR 'S  DIET  FOR  THE  SENILE  HEART 

"Breakfast,  8.30  A.  M. —  Dry  toast,  one  small  piece  —  one  or  one 
and  a  half  ounce  —  with  butter;  one  soft,  boiled  egg,  a  small  piece 
of  whitefish;  three  to  five  ounces  of  tea  or  coffee  with  cream  and 
sugar,  or  an  infusion  of  cocoa  nibs,  or  milk  and  hot  water,  or  cream 
and  Seltzer.  Sometimes  oatmeal  porridge  is  permissible,  but  not 
over  three  or  four  ounces  should  be  taken. 

"Principal  Meal,  1.30  or  2  p.  M. — Fish,  such  as  haddock  or  sole, 
or  meat  and  pudding.  Two  courses  only  are  allowed.  No  soups, 
pickles,  pastry,  or  cheese.  Whitefish  and  short-fibered  meat  only  are 
allowable.  The  fish  may  be  boiled  in  milk.  A  little  spinach  or 
one  potato  may  sometimes  be  eaten,  or  a  half  pound  of  fruit,  such 
as  pears,  apples,  or  grapes.  Four  to  five  ounces  of  hot  water  may 
be  drunk  with  each  meal,  but  no  more. 


532       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

"  5  to  6  P.  M. —  Three  to  four  ounces  of  tea  (one  teacupful)  infused 
for  four  minutes  may  be  drunk,  but  absolutely  no  solid  food  is  to  be 
taken  with  it.  If  desirable,  a  teaspoonful  of  Liebig's  extract  of  meat 
may  be  stirred  in  with  the  tea. 

"  Supper,  7  P.  M. —  Whitefish  and  a  potato  or  toast  and  pudding, 
or  milk  pudding,  or  bread  and  milk,  or  revalenta  made  with  milk  or 
Liebig's  extract. 

"  Bedtime. —  Four  to  five  ounces  of  very  hot  water,  sipped,  helps  the 
patient  to  fall  asleep." 

Upon  this  very  limited  regimen  the  patient,  if  heavy  and  water- 
logged, at  first  loses  weight  by  absorption  of  "  cedematous  soakage," 
or  if  much  wasted  he  may  gain  in  weight.  In  this  manner  the  natural 
equilibrium  of  the  body  is  re-established. 

In  not  too  critical  cases  a  little  more  latitude  is  permitted,  and 
such  vegetables  may  be  eaten  occasionally  as  asparagus,  onions,  leeks, 
tomatoes,  lettuce,  cress.  The  heavier,  coarser  vegetables  (like  cab- 
bage, sprouts,  turnips,  parsnips,  carrots,  beets,  legumes),  pastry,  nuts, 
dried  fruits,  and  sweets  of  all  kinds  are  forbidden,  as  well  as  fried 
food,  twice-cooked  or  "made  over"  dishes,  dried,  canned,  potted, 
pickled  or  preserved  foods  of  all  kinds,  pastry,  cake,  condiments,  and 
confectionery. 

Equal  care  should  be  given  to  the  selection  of  proper  beverages. 
If  there  is  much  palpitation,  tea,  coffee,  and  chocolate  should  be  pro- 
scribed. Cocoa  or  alcathrepta  may  be  drunk  at  5  p.  M.  or  on  re- 
tiring, when  the  stomach  is  empty.  These  beverages  should  not  be 
made  too  sweet. 

No  champagne  or  effervescing  drinks  are  allowed,  and  all  alco- 
holic beverages  should  be  given  only  in  moderation.  If  more  than 
two  ounces  (a  claret-glassful)  of  one  of  the  stronger  wines  is  taken, 
it  excites  acid  dyspepsia,  and  claret,  Burgundy,  or  hock  should  not 
be  allowed  in  greater  measure.  A  small  glass  of  port  or  sherry  may 
be  drunk  twice  a  day;  but,  as  Balfour  observes,  there  is  so  much 
idiosyncrasy  in  the  digestibility  of  wines  that  in  general  plain  liquor 
is  better  for  these  cases  drunk  in  the  small  quantity  recommended  in 
the  menu  given  above.  Alcohol  is  by  no  means  a  necessity,  and 
many  patients  are  better  without  any.  He  has  great  faith  in  the 
stimulating  properties  of  hot  water,  slowly  sipped,  and  says :  "  This 
will  be  found  to  have  quite  as  good  an  immediate  effect  upon  the 
heart  as  alcohol."  It  has  been  shown  elsewhere  that  the  fre- 
quent acts  of  deglutition  performed  in  sipping  any  fluid  tend  to  in- 
crease the  pulse  rate  slightly  through  reflex  stimulation  of  the  vagus 
branches  which  are  concerned  in  the  act. 


ANGINA  PECTOEIS  —  CARDIAC  PALPITATION  533 

As  the  heart  becomes  more  and  more  feeble,  the  inactive  circu- 
lation, perhaps  aided  by  alteration  in  the  composition  of  the  blood 
or  by  albuminuria,  results  in  the  production  of  localized  oedema  or 
general  anasarca. 

In  referring  to  the  use  of  dry  diet  for  these  conditions  as  occur- 
ring in  connection  with  the  senile  heart,  Balf  our  says :  "  When  there 
is  anasarca,  or  any  evidence  of  soakage  in  any  dependent  part  of 
the  body,  it  is  of  the  greatest  importance  to  place  the  patient,  for 
a  time  at  least,  on  the  driest  possible  diet,  and  not  too  much  of 
it.  ...  I  have  seen  a  considerable  amount  of  oedema  of  the  lower 
limbs  disappear  within  twenty-four  hours  before  there  had  been  time 
for  any  change  in  the  heart,  which  was  feeble  and  dilated."  His  dry 
diet  is  as  follows: 

Breakfast. —  A  single  slice  of  dry  toast,  without  butter.  A  cup  of 
tea  (infused  only  four  minutes). 

Dinner. —  Two  lean  chops,  or  their  equivalent  in  chicken  or  fish. 
No  vegetables.  Dry  toast  ad  libitum.  Half  an  ounce  of  brandy, 
whisky,  or  Hollands  in  three  ounces  of  water. 

Supper. —  As  much  dry  toast  as  desired.  Half  an  ounce  of  liquor, 
as  at  dinner. 

Nothing  else  is  allowed;  but  if  the  patient  is  thirsty,  very  hot 
water  may  be  sipped  between  meals.  There  are,  however,  many  cases 
complicated  by  chronic  nephritis,  and  if  too  little  urine  is  being 
voided,  it  may  not  be  safe  to  adopt  the  dry  diet.  In  all  such  com- 
plicated cases,  choice  of  the  lesser  evil  should  be  made. 

ANGINA  PECTORIS 

The  chief  indication  to  be  met  in  the  dietetic  treatment  of  angina 
pectoris  is  to  reduce  the  arterial  tension.  A  vegetable  diet  with  re- 
stricted fluids,  and  no  alcohol,  is  to  be  recommended.  These  patients 
often  are  subjects  of  the  gouty  diathesis,  and  the  directions  for  diet 
in  that  condition  are  to  be  observed.  (See  Gout,  p.  719.)  Meats 
are  likely  to  overcharge  the  system  with  proteid  waste,  which  may 
prove  irritating  and  provoke  an  attack. 

CARDIAC  PALPITATION 

The  dietetic  treatment  of  cardiac  palpitation  is  sufficiently  indicated 
under  the  heading  of  Flatulent  Dyspepsia,  (p.  584).  Overeating 
should  be  avoided,  as  well  as  all  stimulating  foods  and  beverages. 
Tea,  coffee,  and  tobacco  should  be  forbidden  —  at  least  temporarily. 


534       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Effervescing  drinks  of  all  kinds,  from  their  tendency  to  produce  flat- 
ulency, should  also  be  proscribed,  as  well  as  all  sweets  and  much 
amylaceous  food.  Laxative  foods,  especially  fruits,  will  be  found 
useful,  for  the  reason  that  the  primary  cause  of  functional  palpitation 
is  often  autointoxication  from  intestinal  indigestion  or  an  overtaxed 
liver.  (See  Intestinal  Autointoxication,  p.  623.) 


ARTERIOSCLEROSIS 

The  etiology  of  arterio-sclerosis  is  varied.  In  many  cases  it  is 
traceable  to  toxaemias,  as  lead  poisoning,  gout,  chronic  alcoholism, 
or  syphilis.  In  other  cases  it  accompanies  autointoxication  from 
deficient  elimination  of  waste,  as  in  chronic  interstitial  nephritis. 
In  a  very  large  number  of  cases  it  appears  to  be  the  result  of  severe 
mental  or  physical  strain.  In  my  wards  in  Bellevue  Hospital,  filled 
with  representatives  of  the  hardest  working  laboring  classes  —  long- 
shoremen, diggers,  foundrymen,  truckmen,  etc. —  it  is  the  exception 
to  find  a  man  past  thirty-five  years  of  age  who  does  not  present  an 
advanced  grade  of  it.  There  is  some  doubt  as  to  the  influence  of 
diet  as  a  causative  factor,  but  it  is  probably  at  least  a  contributing 
factor,  and  the  results  of  dietetic  treatment  are  often  beneficial.  The 
question  of  fluid  restriction  should  be  decided  upon  the  merit  of  each 
case,  rather  than  by  rule.  Much  fluid  taken  into  an  empty  stomach, 
being  promptly  absorbed,  tends  to  raise  arterial  tension  and  tax  a 
heart  already  working  against  greatly  increased  arterial  resistance, 
thereby  accelerating  cardiac  hypertrophy.  In  cases  complicated  with 
cardiac  dilatation  or  myocarditis,  it  is  desirable  to  restrict  fluids  as 
much  as  possible  in  order  to  lessen  the  weight  of  fluid  that  an  en- 
feebled heart,  already  working  against  great  arterial  resistance,  is 
obliged  to  pump  through  the  circulation.  On  the  other  hand,  too 
little  fluid  ingested  lessens  renal  activity  and  the  excretion  of  waste, 
and  should  be  avoided  whenever  interstitial  nephritis  or  renal  inade- 
quacy exists.  Tobacco  should  be  much  restricted,  and  fried  foods, 
much  fat,  and  any  indigestible  foods  should  be  prohibited. 

The  dietetic  treatment  of  arterio-sclerosis  should  be  substantially 
the  same  as  that  of  lithaemia  (see  Litha3mia,  p.  560),  with  such  com- 
mon-sense modifications  as  the  patient's  social  position  may  dictate. 
It  is  futile  to  tell  a  day  laborer  to  lie  down  and  rest  before  or  after 
his  meals,  but  it  is  possible  to  keep  his  elimination  of  waste  products 
active  through  catharsis  and  diuresis,  and  to  regulate  his  diet,  while 
it  may  ho  possible  to  induce  him  to  drink  water  occasionally,  in  lieu 
of  poor  beer  and  worse  whisky. 


ANEURISM  535 

In  those  cases  in  which  renal  inadequacy  is  a  pronounced  feature 
it  will  be  well  to  put  the  patient  upon  a  milk  diet  for  several  weeks. 
In  general,  a  non-stimulating  diet  is  requisite,  with  a  minimum  of 
butcher's  meat,  and  no  strong  condiments,  richly  cooked  dishes,  or 
alcohol  should  be  allowed.  If  too  much  red  meat  be  eaten  the  ex- 
tractives irritate  the  vascular  system  and  increase  arterial  tension. 
Although  white  meats  contain  slightly  less  proteid  than  red,  they  are 
alike  in  the  quantity  of  extractives  present,  hence  a  diet  largely  vege- 
tarian is  to  be  recommended  in  this  condition.  Patients  living  in 
lime-water  districts  should  obtain  some  less  harmful  potable  water, 
such  as  Poland  or  Manitou. 

SUMMARY  OF  FOODS  FOR  ARTERIO-SCLEROSIS. 

Fish  of  any  kind.     Roe. 

Meats:  Tongue,  ham,  bacon,  tripe,  liver,  sweetbread  (as  substi- 
tutes for  beef  and  mutton). 

Vegetables:  Potatoes  (white  or  sweet),  peas,  corn,  beets,  spinach, 
cabbage,  cauliflower,  Brussels  sprouts,  onions,  celery,  lettuce,  turnips, 
parsnips,  string,  Lima  and  butter  beans,  eggplant,  oyster  plant, 
tomatoes,  cucumbers,  radishes,  carrots. 

Butter,  milk,  buttermilk,  cheese. 

Eggs  in  any  form.     Custards. 

Cereals:  Oatmeal,  rolled  oats,  rice,  puffed  rice,  wheatena,  wheaten 
grits,  trisket,  shredded  wheat,  hominy,  cornmeal.  White  and  Gra- 
ham bread. 

Gelatin  food's;    Wine  jelly,  blancmange,  unsweetened  fruit  jellies. 

Fruits:  Oranges,  lemons,  grape  fruit,  apples  (raw,  baked  or 
stewed),  apple  sauce,  plums,  prunes,  pears,  peaches,  grapes,  cherries, 
berries  of  any  sort,  melons. 

The  more  fruit  and  green  vegetables  the  better.  As  the  disease  is 
permanent,  it  is  not  well  to  give  up  red  meats  indefinitely.  A  good 
rule  is  to  turn  vegetarian  for  definite  periods,  of  say  6  weeks,  and 
then  eat  meat  sparingly  twice  a  week,  or  every  other  day  and  never 
more  than  once  daily. 

Beverages:  Tea  and  coffee  in  great  moderation,  cocoa,  chocolate, 
effervescing  waters,  lemonade. 

ANEURISM 

In  "  aneurism  "  of  the  large  arteries  the  vascular  wall  is  dilated  and 
thinned,  and  rupture  is  liable  to  occur  at  any  time  from  increase 
of  the  blood  pressure  or  obstruction  to  the  circulation  produced  by 


536       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

sudden  movement,  or  otherwise.  The  most  favorable  result  of  treat- 
ment which  may  be  anticipated  is  thickening  of  the  diseased  vessel 
by  the  deposit  of  coagulated  fibrin.  The  coagulability  of  the  blood 
varies  with  its  composition,  and  is  favored  by  increased  density  of 
the  blood  and  by  quantitative  change  in  its  fibrin.  To  a  limited 
extent  this  process  may  be  aided  by  diet.  The  feeding  of  patients 
with  gelatin  has  been  recommended,  on  the  ground  that  gelatin 
notably  increases  the  firmness  of  clotted  blood,  but  it  is  so  altered 
in  the  process  of  digestion  and  absorption  as  to  be  of  no  practical 
value  for  aneurism. 

The  real  object  to  be  attained  in  the  dietetic  treatment  of  aneu- 
rism is  to  reduce  the  volume,  and  consequently  increase  the  density  of 
the  blood.  The  latter  does  not  necessarily  increase  its  coagulability, 
unfortunately.  This  method  of  treatment  was  originally  formulated 
by  Bellingham  and  Joliffe  Tufnell,  of  Dublin,  and  it  is  now  described 
by  the  latter's  name.  It  is  only  less  strict  than  the  very  old  method 
of  Valsalva,  who  gave  half  a  pound  of  pudding  morning  and  evening, 
and  nothing  else  —  practical  starvation!  In  conjunction  with  the 
dietetic  treatment  absolute  rest  of  the  patient  is  enjoined;  he  should 
lie  horizontally  in  bed,  and  not  be  permitted  to  make  exertion  of  any 
kind,  and  mental  strain  and  emotion  should  carefully  be  guarded 
against.  He  should  be  fed  by  a  nurse,  and  not  allowed  to  sit  up  at 
any  time.  By  rest  alone  the  rate  of  the  heart  beat  is  materially 
slowed,  and  this  is  aided  also  by  the  reduced  diet.  The  aneurism, 
in  consequence,  is  distended  less  often  and  submitted  to  less  pressure, 
The  treatment  originally  recommended  by  Tufnell  is  as  follows : 

TUFNELL 'S   DIET 

Breakfast. —  Two  ounces  of  bread  with  a  little  butter  and  two 
ounces  of  milk.  Dinner. —  From  two  to  three  ounces  of  meat  without 
salt  and  four  ounces  of  milk;  for  a  portion  of  the  milk  an  ounce  or 
two  of  claret  may  be  substituted.  Supper. —  The  same  as  at  break- 
fast, 

This  extremely  strict  diet  is  rebelled  against  by  most  patients,  but 
it  serves  as  a  basis  for  the  commencement  of  other  treatment,  and 
if  it  be  impracticable  to  adhere  to  it,  the  quantity  of  food  will 
have  to  be  slightly  increased.  It  may  be  necessary  to  double  the 
quantity  of  milk  and  increase  that  of  bread  or  vary  it  with  crackers 
or  some  light  form  of  amylaceous  diet.  The  fluid,  however,  is  in  all 
cases  to  bo  restricted  as  much  as  possible.  Patients  usually  complain 
bitterly  of  thirst,  and  while  it  is  more  desirable  to  restrict  the  fluids 
than  the  solids  in  the  dietary,  the  thirst  may  be  alleviated  somewhat 


ANEMIAS  —  CHLOROSIS  537 

by  acidulated  drinks,  such  as  sour  lemonade,  dilute  phosphoric  acid 
in  cinnamon  water,  etc.  A  "  salt  free  "  diet  also  may  lessen  thirst. 
(See  p.  556.)  If  the  bread  and  butter  be  made  without  salt,  and  none 
be  added  as  a  condiment  with  meals,  the  Tufnell  diet  becomes  prac- 
tically salt  free.  The  danger  which  menaces  the  patient  and  the  ob- 
ject of  his  treatment  should  be  explained  clearly  to  him  and  his 
co-operation  secured  in  the  effort  for  relief.  Upon  this  reduced  diet 
improvement  in  physical  signs  of  the  aneurism  —  such  as  dimin- 
ished pulsation  and  intensity  of  bruit  and  lessened  pain  —  is  occa- 
sionally decided.  In  favorable  cases  improvement  may  be  looked  for 
at  the  end  of  a  week,  and  if  the  dietetic  treatment  be  persisted  in  for 
six  weeks,  the  benefit  may  be  considerable.  Tufnell  reported  several 
cases  in  which  the  aneurismal  sac  became  lined  with  a  thick  coating 
of  fibrin. 

There  are  many  cases  of  aneurism  outside  the  province  of  surgi- 
cal treatment  which  are  incapable  of  relief  from  any  diet,  but  the 
method  above  described  is  worthy  of  trial  in  an  otherwise  hopeless 
condition.  I  have  several  times  known  it  to  produce  considerable 
lessening  of  pain,  dyspnoea,  and  other  symptoms,  but  it  requires  firm- 
ness and  perseverance  to  carry  it  out  successfully.  The  curative  re- 
sults have,  unfortunately,  not  verified  TufnelPs  original  claims,  and 
as  pointed  out  by  the  late  A.  L.  Loomis,  if  the  method  be  too  rigidly 
and  too  long  enforced  —  for  six  or  eight  weeks  —  an  extreme  degree 
of  anaemia  may  develop  and  leave  the  patient  worse  off  than  before. 

If  the  Tufnell  diet  is  not  prescribed,  non-stimulating  food  only 
should  be  allowed,  consisting  chiefly  of  simply  cooked  fresh  vege- 
tables, cereals,  and  fruits,  with  but  little  meat  and  no  coffee,  tea,  con- 
diments, or  spices.  Anything  likely  to  produce  flatulency  or  gastric 
dyspepsia  should  be  avoided,  alcohol  should  be  forbidden,  and  all 
fluids  should  be  drunk  slowly  and  in  small  quantities  at  a  time. 

ANEMIAS  —  CHLOROSIS,  ETC. 

Pathological  Physiology. —  The  proper  nutrition  of  all  the  tissues 
of  the  body  is  directly  dependent  upon  the  quality  of  the  blood 
plasma  and  of  the  quantity  of  oxygen  conveyed  by  the  corpuscles. 
A  very  slight  departure  from  the  average  composition  of  these  ele- 
ments will  sooner  or  later  result  in  diminishing  the  nutrition  and 
functional  activity  of  all  the  organs  in  the  body,  notably  those  of  the 
digestive  system. 

Ana?mia,  whether  acute  and  due  to  hemorrhage  or  disease,  or 
chronic  from  any  cause,  by  depleting  the  cellular  elements  of  the 


538       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

blood,  interferes  with  the  proper  oxidation  of  food  after  absorption. 
On  the  other  hand,  a  diet  which  is  sufficient  in  amount  or  inappro- 
priate in  quality,  if  long  continued,  is  certain  to  produce  an  impov- 
erished condition  of  the  blood  with  a  diminution  in  the  number  of 
corpuscles  or  structural  changes  in  them ;  hence  there  is  a  double  rela- 
tion existing  between  the  power  of  the  blood  to  insure  complete 
absorption  and  metabolism,  and  of  the  food  itself  to  maintain  the 
normal  balance  of  the  ingredients  of  the  blood.  Anemia,  therefore, 
demands  special  feeding,  the  basis  of  which  should  be  an  effort  to  re- 
store as  soon  as  possible  the  -proper  number  of  red  corpuscles  and  the 
normal  quantity  of  other  ingredients  of  the  blood  (especially  protein). 
When  proteid  food  is  excluded  from  the  diet  for  some  weeks  the 
hemoglobin  of  the  red  blood  corpuscles  may  be  reduced  considerably 
in  amount  and  hydraBmia  ensues,  but  the  pigment  is  increased  by  an 
excess  of  proteid  food. 

Chlorosis  is  most  common  at  the  age  of  puberty,  and  shortly  there- 
after, among  young  girls  who  are  growing  or  who  are  overworked  at 
school  or  in  factories  while  beginning  menstruation,  and  who  are  im- 
properly fed.  It  is  observed  among  young  servant  girls  who  live 
largely  upon  tea  and  toast.  The  disease  is  far  less  frequently  en- 
countered at  the  present  time,  since  the  "  outdoor  life  "  has  come  into 
vogue.  The  diversion  of  considerable  nervous  energy  for  other  func- 
tions than  those  of  the  circulation  at  this  time  may  interfere  some- 
what with  the  nervous  mechanism  of  digestion  and  absorption.  In 
other  cases  there  is  a  constitutional  or  hereditary  weakness  of  the 
digestive  system,  which  is  intensified  by  exceptional  strain  or  over- 
work of  the  nerves.  At  the  period  of  growth  and  development,  there 
are  always  unusual  demands  upon  the  nervous  system,  and  overstrain 
at  this  time  is  especially  to  be  guarded  against.  Prolonged  constipa- 
tion, giving  rise  to  intestinal  autointoxication,  is  a  potent  factor  in 
maintaining,  if  not  also  in  causing  anemic  conditions. 

Symptoms. —  Among  the  many  symptoms  referable  to  the  nervous 
system  which  arise  in  the  course  of  protracted  ansemia  are  languor, 
vertigo,  various  forms  of  neuralgia  and  megrim,  with  indefinite  mus- 
cular pains,  which  to  some  extent  are  produced  by  enfeebled  circula- 
tion, which  allows  waste  material  produced  by  muscular  action  to 
accumulate  in  the  tissues.  Depression  of  spirits  and  drowsiness  are 
also  observed,  and  palpitation  is  easily  excited.  The  poor  circulation 
may  result  in  the  production  of  fainting,  or  of  cedema  in  the  lower 
extremities.  In  advanced  anaemia  it  is  found  that  not  only  is  the 
normal  rate  of  tissue  metabolism  impaired,  but  there  may  be  modifica- 
tions in  the  relative  consumption  of  certain  foods  by  the  tissues.  A 


ANEMIAS  —  CHLOROSIS  539 

large  excess  of  urea  is  commonly  observed,  which  indicates  an  active 
combustion  of  proteids.  Owing  to  the  small  number  of  the  red  blood 
disks,  or  oxygen  carriers,  or  their  poor  structure,  the  final  oxidation  of 
fatty  matter  is  retarded,  and  it  is  for  this  reason  that  anaemic  subjects 
often  appear  plump  or  even  corpulent  from  the  deposition  of  a  large 
amount  of  fat  derived  from  incomplete  combustion  of  fats  and  starches, 
whereas  their  muscles,  from  the  increased  proteid  waste,  are  reduced 
in  size  and  weak.  Von  Noorden,  Kraus,  Bohland,  and  others  believe 
that  whereas  chlorotic  patients  feel  tired,  sleep  long,  and  are  disin- 
clined to  expend  energy  in  muscular  exertion,  less  energy  than  usual 
goes  into  heat  production,  and  as  they  sometimes  eat  abundantly  of 
sugars,  and  starches,  they  necessarily  store  up  fat. 

Rest,  Exercise,  and  Air. —  In  cases  of  extreme  anaemia,  found 
especially  among  young  chlorotic  girls,  the  dietetic  treatment  should 
be  accompanied  by  careful  regulation  of  all  hygienic  conditions. 
Sufficient  rest  for  the  tissues,  and  especially  for  the  digestive  organs, 
should  be  secured.  These  patients,  who  appear  so  well  nourished, 
may  in  reality  be  quite  weak,  and  it  is  a  mistake  to  compel  them  to 
rise  early  and  perform  tasks  and  indulge  in  exercises  of  the  same 
character  and  degree  with  those  of  healthy  persons.  For  many  pa- 
tients it  is  well  to  insist  on  a  prolonged,  continuous  rest  in  bed.  For 
others  it  will  suffice  to  restrict  the  activities  of  the  day  by  permitting 
the  patient  to  rise  shortly  before  noon,  and  to  insist  upon  rest  being 
taken  on  a  lounge  both  before  and  after  meals  in  order  to  secure 
more  perfect  digestion.  These  patients  should  be  cautioned  against 
allowing  themselves  to  become  unduly  fatigued.  They  are  often  able, 
under  the  influence  of  stimulants  and  excitement  of  various  sorts,  to 
perform  feats  of  exercise  or  endurance  which  are  equal  to  those  of 
healthy  persons,  but  a  strong  reaction  is  certain  to  follow,  and  a 
steady  but  slow  improvement  may  be  checked  by  infringement  of  nec- 
essary regulation.  As  soon  as  decided  improvement  is  evident,  and  in 
all  the  milder  cases,  it  is  desirable  to  enforce  rules  for  gentle  exercise 
in  the  open  air,  and  the  patient  should  sit  outdoors  nearly  all  the  re- 
maining time  whenever  the  weather  permits.  The  exercise  should  be 
supervised  and  slowly  increased  in  stout  subjects,  so  that  they  gradually 
consume  their  superfluous  fat.  If  the  climate  is  unfavorable  the  cure 
will  be  more  rapid  if  the  patient  can  be  moved  to  a  more  salubrious 
locality.  Fresh  air  is  more  important  than  exercise  or  iron,  for  an 
abundant  oxygen  supply  increases  the  appetite  and  distinctly  promotes 
assimilation  of  the  food. 

Dietetic  Treatment  —  The  dietetic  treatment  of  anaemia  requires, 
in  the  first  place,  that  the  most  nutritious  food  should  be  supplied; 


540       DIET  IN  DISEASES  OF  THE  CIECULATORY  SYSTEM 

secondly,  care  should  be  taken  to  insure  its  complete  digestion  and 
absorption.  In  all  cases  of  serious  anaemia  the  impoverished  and 
watery  condition  of  the  blood  reacts  unfavorably  upon  the  character 
of  the  digestive  secretions  and  diminishes  their  organic  elements. 
The  secretions  are  therefore  unable  to  digest  the  food  with  the  neces- 
sary vigor,  and  it  is  often  desirable  to  re-enforce  them  by  the  use  of 
artificially  prepared  ferments  or  to  give  predigested  food,  making 
use  of  pancreatin,  in  the  preparation  of  animal  food,  and  diastase  or 
malt  extracts  for  the  predigestion  of  amylaceous  food  (see  pp. 
188,  189.) 

At  the  commencement  of  treatment  rest  and  a  small  quantity  of 
food  may  be  required,  but  with  improvement  of  the  digestive  organs 
the  quantity  of  food  may  be  increased  rapidly,  and  four  or  five  meals 
a  day  may  be  given.  At  first,  if  milk  is  well  borne  by  the  enfeebled 
digestive  system,  and  if  it  is  not  distasteful  to  the  patient,  it  should 
be  the  principal  food.  It  may  be  drunk  between  meals,  and  espe- 
cially at  night  on  going  to  bed.  Some  of  these  patients  who  cannot 
digest  milk  with  facility  are  able  to  take  a  mixture  of  equal  parts  of 
cream  and  hot  water  with  ten  grains  of  bicarbonate  of  soda.  Eggs  in 
all  forms  which  are  of  fairly  easy  digestion  are  an  excellent  food 
for  anasmic  subjects,  and  rare  meat  should  be  given  in  considerable 
quantities  two  or  three  times  a  day.  Sandwiches  made  with  pounded 
meat  or  beefsteak  almost  raw,  which  is  placed  between  thin  slices  of 
bread  and  butter,  may  be  taken  with  meals,  or  as  a  light  lunch  in  the 
middle  of  the  morning  and  afternoon.  Inserting  a  crisp  lettuce  leaf 
in  each  sandwich  makes  it  still  more  palatable  and  wholesome.  Pa- 
tients of  this  class  often  object  very  strongly  to  eating  meat,  and 
prefer  pastry  and  sweets,  but  with  tact  and  persuasion  they  may 
usually  be  induced  to  take  it  in  some  form.  Meat  broths  and  con- 
sommes may  be  thickened  with  scraped  meat,  or  raw  scraped  beef  may 
be  added  to  chocolate  or  Burgundy,  or  may  be  eaten  in  any  manner 
agreeable  to  the  patient.  In  this  way  large  quantities  of  meat  in  an 
easily  digestible  form  may  be  taken  without  tiring  of  it,  as  fat  anaamic 
women  are  very  apt  to  do.  Young  chlorotic  girls  should  receive  at 
least  five  or  six  ounces  of  albumin  per  diem.  See  gives  as  much  as 
fourteen  ounces  of  raw  meat  daily  in  some  cases  of  chlorosis, 
and  finds  it  especially  serviceable  for  those  patients  whose  weak 
stomachs  rebel  against  the  use  of  the  different  preparations  of 
iron. 

Anaemic  patients  often  feel  worse  during  the  first  half  of  the  day. 
They  then  complain  most  of  headache,  languor,  and  anorexia,  but 
they  should  be  encouraged  to  begin  the  day  early  with  nourishing 


ANEMIAS  —  CHLOROSIS  541 

albuminous  food  to  counteract  this  condition.  Von  Noorden's  system 
is  excellent,  and  he  describes  it  as  follows: 

"  I  recommend  chlorotic  girls  to  drink  slowly  half  a  liter  [one  pint] 
of  milk  of  the  best  quality  while  they  are  yet  in  bed  in  the  morning. 
They  must  take  time,  and  occupy  at  least  a  quarter  of  an  hour  in  con- 
suming this  quantity.  They  ought  to  rise  half  an  hour  later,  and 
they  should  be  rubbed  briefly  with  a  dry  rough  woolen  towel.  This 
is  to  be  followed  by  the  breakfast,  consisting  of  a  small  cup  of  tea, 
one  or  two  slices  of  buttered  toast,  and  plenty  of  meat.  I  consider 
it  extremely  desirable  —  the  physiological  reasons  for  this  are  easy 
to  defend  —  that  these  patients  should  take  in  at  breakfast,  before  the 
daily  work  commences,  as  much  albumin  as  possible.  Two  and  a  half 
hours  later  some  bread  and  butter  and  two  eggs  are  to  be  eaten,  fol- 
lowed immediately  afterwards  by  drinking  a  quarter  of  a  liter  [one- 
half  pint]  of  milk/' 

If  the  large  quantities  of  meat  recommended  are  not  perfectly 
digested  and  absorbed,  it  is  well  to  prescribe  nux  vomica  with  dilute 
hydrochloric  acid.  A  concentrated  meat  diet  almost  always  produces 
constipation  if  this  condition  does  not  exist  already  as  a  result  of  the 
anaemic  and  atonic  condition  of  the  intestinal  wall,  or  the  giving  of 
iron.  It  is  well  to  counteract  this  tendency  by  the  use  of  draughts 
of  hot  water  and  of  purees  of  fresh  vegetables,  whole-meal  bread, 
oatmeal,  and  such  fruits  as  stewed  prunes,  apples,  and  the  juice  of 
oranges  and  grape  fruit.  (See  Constipation,  p.  636.) 

The  various  Italian  pastes,  such  as  macaroni,  vermicelli,  and 
polenta,  with  meat  gravies,  are  suggested  by  Yeo.  But  with  those 
patients  in  whom  there  is  a  tendency  to  overproduction  of  fat,  with- 
holding of  hydrocarbons  from  the  diet  is  highly  desirable. 

For  others  who,  besides  being  anaemic,  are  thin  and  poorly  nour- 
ished, it  is  well  to  add  some  simple  forms  of  starchy  food  and  a  liberal 
allowance  of  fat  with  the  meals.  Von  Noorden  says: 

"  For  a  well-nourished,  moderately  fat,  chlorotic  girl,  weighing  125 
Ibs.,  I  would  consider  the  following  diet  eminently  suitable : 

"  120  grams    (4  ozs.)   protein  —     492  calories. 

60       "         (2  ozs.)    fat  =      558 

270       "         (9  ozs.)    carbohydrates  =  1,110        " 

Total    2,160 

(i.  e.,  36  calories  per  kilo  of  body  weight.)  " 

The  eating  of  fats  is  to  be  increased  to  the  limit  of  toleration. 
Cream  and  large  quantities  of  butter  are  recommended  when  easily 
digested,  and  they  may  be  made  to  replace  cod-liver  oil  when  the 


542       DIET  IN  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

patient  is  unable  to  take  this  form  of  fat,  Many  patients  digest 
broiled  fat  bacon  with  ease.  Two  or  three  eggs  beaten  with  boiling 
water  or  milk,  with  the  addition  of  sugar  and  spices,  may  be  given  two 
or  three  times  during  the  day  between  meals. 

The  use  of  glycerin  extracts  and  emulsions  of  bone  marrow  has 
been  advocated  for  anaemia,  but  the  results  have  not  been  markedly 
satisfactory.  The  method  of  preparation  is  described  on  p.  233. 

The  majority  of  anaemic  patients  have  no  appetite,  or  lose  it,  during 
the  early  part  of  the  day,  and  careful  attention  should  be  given  to 
making  all  food  as  agreeable  to  them  as  possible  in  taste  and  manner 
of  serving.  Meat  should  be  prepared  so  as  to  require  the  least  possi- 
ble effort  in  mastication,  and  much  additional  food  should  be  con- 
sumed in  a  fluid  and  semisolid  form. 

Simple  condiments  are  serviceable,  for  they  render  food  more 
agreeable  and  stimulate  the  enfeebled  gastric  secretion.  Moleschott 
insists  on  the  free  use  of  salt  by  chlorotic  patients  on  account  of  its 
alleged  favorable  action  in  restoring  the  blood  corpuscles  and  plasma. 

Alcohol  is  not  indicated  for  all,  but  there  are  some  patients  who 
are  benefited  by  its  use,  and  a  good  form  of  alcoholic  tonic  for  an 
anaemic  patient  is  a  rich  claret,  Burgundy,  or  Madeira.  Some  of 
the  milder  cases,  especially  in  women  in  whom  the  digestive  organs 
are  not  particularly  disturbed,  do  very  well  on  porter  or  stout,  or 
one  of  the  various  malt  preparations,  which  may  be  taken  with  the 
noonday  meal  or  at  bedtime  with  a  few  crackers  or  a  raw-beef  sand- 
wich. The  latter  is  a  prescription  very  serviceable  in  those  cases  in 
which  insomnia  is  a  harassing  symptom.  There  is  no  apparent  con- 
nection whatever  between  the  absorption  of  alcohol  and  the  forma- 
tion of  new  blood  cells,  although  there  is  a  popular  idea  to  the  effect 
that  red  wine  produces  red  blood.  Alcohol,  however,  often  does  pro- 
mote the  accumulation  of  fat,  and  this  is  undesirable  in  anaemic 
subjects  who  already  possess  that  tendency. 

SUMMARY  OF  DIET  FOB  SIMPLE  FUNCTIONAL  ANAEMIAS 

Meats:  Rare  roast  beef,  steak,  chops,  lamb,  mutton,  ham,  bacon, 
tongue,  chicken,  turkey. 

Eggs:  Beaten  raw,  or  boiled,  scrambled,  or  as  an  omelette.  Cus- 
tards. 

Fish:  Fresh  fish  of  any  sort  boiled  or  broiled,  but  not  fried  or 
baked. 

Cereals:  Graham  bread,  brown  bread,  oatmeal,  wheaten  grits, 
hominy,  corn  broad. 

VcyctahJt'x:     AVliite  potatoes,  baked,  mashed,  or  "creamed,"  string 


PERNICIOUS   ANAEMIA  543 

beans,  lettuce,  celery,  spinach,  tomatoes.  (There  is  no  objection  to 
vegetables,  but  if  too  much  variety  is  eaten,  less  meat  will  be  taken.) 

Milk,  buttermilk,  cream,  butter. 

Desserts:  Junket,  blancmange,  wine  or  lemon  jelly,  bread  pud- 
ding, rice  pudding  with  stewed  fruit. 

Fruits:  Oranges,  peaches,  plums,  pears,  melons,  nectarines,  apri- 
cots, tamarinds,  grapes,  limes,  lemons,  grape  fruit,  strawberries,  ap- 
ples (raw  or  cooked),  olives. 

Beverages:     Cocoa,  koumiss,  lemonade,  orangeade. 

Foods  Forbidden :  Fried  foods,  twice  cooked  and  "  made  over " 
dishes,  pastry,  confectionery,  "cakes,"  cake,  "preserves,"  jams,  vine- 
gar, pickles,  gravies,  sauces,  nuts,  raisins,  canned,  dried,  salted,  and 
preserved  foods  of  all  kinds.  Tea  and  coffee,  as  a  rule. 

PERNICIOUS  ANEMIA 

The  most  successful  treatment  of  pernicious  anaemia  is  based  upon 
securing  comparative  asepsis  of  the  alimentary  canal.  The  mouth 
should  be  cleansed  thoroughly  with  an  antiseptic  wash  always  after 
taking  food  and  the  teeth  should  be  put  in  the  best  possible  order. 
Effort  should  be  made  to  avoid  gastric  and  intestinal  malfermenta- 
tion  which  results  in  flatulency,  constipation  and  autointoxication. 
I  have  obtained  the  best  results  from  careful  dieting,  abundant  fresh 
air,  laxatives  and  daily  intestinal  irrigation  with  salt  solution.  Lac- 
tobacilline  should  be  used  (p.  92).  Fresh  fruit  and  fresh  green  veg- 
etables are  recommended,  such  as  oranges,  lemons,  grape  fruit,  apples, 
string  beans,  lettuce,  celery,  tomatoes  (not  canned),  and  potatoes. 
Red  meat  should  be  given  not  more  than  once  a  day  and  it  may  be 
made  to  alternate  with  chicken,  fish,  bacon,  and  eggs.  Water  should 
be  drunk  between  meals  in  considerable  quantity  —  five  or  six  tum- 
blerfuls  a  day, —  and  after  eating  meats,  dilute  hydrochloric  acid  in 
large  doses  with  nux  vomica  is  indicated.  In  about  one-half  of  all  the 
cases  gastric  atony  is  present,  hence  the  desirability  of  supplementing 
deficient  gastric  secretion. 

DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

INFLUENCE  OF  DIET  ON  THE  URINE 

The  quantity  as  well  as  the  composition  of  the  food  eaten  exer- 
cises an  important  influence  over  the  composition  of  the  urine. 
Animal  food  increases  the  acidity  of  the  urine  and  naturally  also- 


544  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

its  nitrogenous  elements,  urea,  uric  acid,  and  urates;  and  vegetable 
food  increases  the  carbonates  and  earthy  salts.  A  concentrated  diet 
restricted  in  fluids  as  well  as  solids  reduces  the  water  of  the  urine, 
and  makes  it  relatively  more  acid,  although  the  absolute  quantity  of 
acid  may  not  be  increased.  Conversely,  watery  foods,  milk,  succulent 
fruits  and  vegetables,  and  all  beverages  increase  the  quantity  of 
urinary  fluid  and  tend  thereby  to  lessen  its  acidity  and  density. 
Cantani  dissents  from  the  common  view  that  the  organic  acids,  such 
as  fruit  acids,  form  carbonates  which  promote  alkalinity  of  the  urine, 
and  says  that  this  is  true  of  small  quantities,  but  that  larger  amounts 
or  the  continued  administration  of  these  acids  makes  the  urine 
strongly  acid.  Phosphaturia  or  the  excessive  deposit  of  phosphates 
in  the  urine  is  best  treated  dietetically  by  the  use  of  meats,  eggs, 
cheese,  cereals,  and  legumes.  Potatoes,  fresh  green  vegetables,  and 
fruits  should  be  avoided. 

A  diet  rich  in  fatty  food,,  or  an  excess  of  cod-liver  oil,  may  some- 
times give  rise  to  fat  in  urine,  or  lipuria.  The  volatile  fatty  acids 
may  be  present.  The  presence  of  the  fat  makes  the  urine  somewhat 
turbid,  and  oil  globules  and  fat  crystals  sometimes  may  be  seen  under 
the  microscope.  A  milk  diet  makes  the  urine  alkaline,  and  increases 
the  indican. 

Foods  producing  oxaluria  are  described  under  Oxaluria,  p.  557. 

The  odor  imparted  by  asparagus  to  the  urine  is  explained  on  p.  204. 

(See  also  The  Urine  and  Food,  p.  403.) 

ACUTE  NEPHRITIS 

Symptoms. —  Acute  nephritis  is  an  inflammation  of  the  kidneys, 
principally  caused  by  exposure  to  cold  and  wet,  by  certain  medicinal 
poisons,  or  by  the  toxins  developed  in  the  course  of  acute  infectious 
fevers,  especially  the  exanthemata  and  diphtheria.  It  is  unnecessary 
to  discuss  its  varieties  here,  as  the  dietetic  treatment  is  the  same 
for  all. 

Among  the  important  symptoms  are  anaemia  and  a  scanty  secre- 
tion of  urine  containing  abundant  serum  albumin  with  casts  and 
blood.  Anasarca  and  effusion  into  various  serous  cavities,  such  as  those 
of  the  pleura  and  peritonaeum,  may  occur.  The  arterial  tension  is 
increased. 

Dietetic  Treatment. —  The  dietetic  treatment  should  be  adapted  to 
prevent  overloading  the  digestive  organs,  which  are  easily  deranged, 
and  to  prevent  overworking  the  kidneys.  A  light  diet  is  therefore 
necessary.  The  patient  will  do  best  to  live  exclusively  upon  milk  for 


ACUTE  NEPHRITIS  545 

some  days,  until  the  functional  activity  of  the  kidneys  is  restored. 
The  importance  of  this  should  be  explained  to  him  and  insisted  upon. 
Between  four  and  seven  pints  are  to  be  taken  daily,  diluted  with  Vichy 
or  carbonic-acid  water.  If  the  bowels  are  loose,  lime  water  may  be 
added  instead;  or  if  constipated,  magnesia  solution.  If  the  liver 
seems  inactive,  skimmed  milk  or  buttermilk  may  agree  better.  Milk 
sometimes  causes  gastric  oppression.  If  sipped  slowly,  or  taken  with 
a  teaspoon,  this  may  be  overcome,  for  it  is  then  diluted  with  the 
saliva. 

If  milk  is  strenuously  objected  to  or  disagrees  with  the  patient, 
other  simple  foods  may  be  allowed,  such  as  koumiss,  buttermilk,  and 
gruels  of  oatmeal,  groats,  rice,  barley,  flour,  or  arrowroot,  or  toast 
or  crackers  may  be  eaten  in  the  milk.  These  forms  of  starchy  food 
should  be  prepared  without  much  sugar,  but  a  little  cream  may  be 
added  or,  if  preferred,  the  juice  of  a  lemon,  but  no  vegetables  are 
permitted.  Animal  broths  dissolve  substances  from  meat  which  may 
develop  into  toxins  and  irritate  the  kidneys. 

When  the  kidneys  become  more  active  and  the  character  of  the 
urine  improves,  the  diet  may  be  increased  by  such  articles  as  bread 
and  butter,  cream  toast,  plain  puddings,  such  as  sago,  farina,  or  corn- 
starch,  lettuce,  or  water  cress  with  plain  French  dressing,  stewed 
apples,  grapes,  oranges,  etc.,  but  whenever  possible  the  food  should 
consist  largely  of  milk  for  a  long  period.  Later,  eggs  and  meat  broths 
may  be  allowed,  and  finally  a  little  white  meat  of  poultry,  bacon,  fish, 
oysters,  and  squab. 

Any  return  of  the  albuminuria  should  immediately  be  met  by  a 
reduction  in  the  diet  to  its  original  simplicity  —  chiefly  milk. 

A  patient  may  lose  thirty  or  forty  grains  of  serum  albumin  in 
twenty-four  hours  without  serious  harm,  but  if  three  to  four  hundred 
grains  are  lost  the  condition  is  in  itself  alarming,  for  he  is  losing 
one-fifth  to  one-fourth  of  his  total  proteid  food  through  leakage 
of  the  kidneys  —  i.  e.,  he  is  passing  daily  in  the  urine  one-twelfth  of 
the  nutrient  matter  of  his  blood  (Granger  Stewart).  A  pint  of  milk 
supplies  about  an  ounce  of  albumin  and  casein,  thus  replenishing  the 
waste. 

Milk,  sugar,  or  lactose  is  sometimes  given  separately  for  its  diuretic 
action.  See  gives  it  up  to  three  ounces  in  twenty-four  hours,  to  be 
drunk  in  two  quarts  of  water,  and  he  believes  it  acts  best  when  car- 
diac dropsy  is  also  present  and  the  quantity  of  albumin  is  not  large, 
I  have  found  it  difficult  to  push  its  use  to  such  a  degree  without 
causing  dyspepsia  and  a  decided  dislike  for  it.  Milk  is  undoubtedly 

a  good  mild  excitant  of  renal  activity,  but  this  is  due  to  its  water  as 
37 


546  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

much  as  to  any  other  ingredient,  and  the  diuretic  effect  of  lactose  is 
much  overrated,  although  it  furnishes  abundant  heat  units. 

Should  vomiting  occur  at  any  time,  the  diet  should  be  reduced,  or 
it  may  be  advisable  to  give  the  stomach  complete  rest  for  ten  or  twelve 
hours.  To  increase  the  activity  of  the  skin  and  wash  the  casts  and 
debris  of  granular  matter  and  blood  corpuscles  from  the  renal  tubules, 
the  blood  volume  may  be  raised  by  ingestion  of  abundant  fluid,  pro- 
vided the  tendency  to  dropsical  effusions  is  not  great.  Water,  alka- 
line, mineral,  or  effervescing  waters,  soda  lemonade,  or  cream-of- 
tartar  lemonade  should  be  drunk  freely,  the  latter  especially  if  there  is 
constipation  (Dickinson).  Osier  recommends  the  following:  A 
drachm  of  cream  of  tartar  in  a  pint  of  boiling  water  with  the  addi- 
tion of  the  juice  of  half  a  lemon  and  a  little  sugar.  To  be  drunk 
cold. 

It  is  a  general  rule  to  exclude  all  foods  and  drinks  which  may  in 
any  way  irritate  the  kidneys,  and  the  following  are  especially  forbid- 
den during  convalescence:  Grills,  roasts,  sauces,  pastry,  spices,  pick- 
les, preserves,  rich  cake,  very  acid  foods,  strong  alcoholic  drinks,  tea 
and  coffee.  Strong  wines,  sweet  wines,  and  all  sorts  of  liqueurs  are 
absolutely  prohibited. 

ACUTE  NEPHRITIS  IN  CHILDREN 

When  the  disease  occurs  in  children,  as  often  happens  during  or 
after  acute  infectious  diseases,  such  as  scarlatina  and  diphtheria,  the 
diet  should  consist  exclusively  of  milk.  During  the  most  acute  stage 
of  nephritis  the  milk  may  be  diluted  one-half  with  Vichy  or  water 
for  its  diuretic  influence.  It  should  be  given  in  moderation,  but 
often  —  say  at  least  once  in  two  hours.  As  the  acute  symptoms  sub- 
side milk  is  to  be  ordered  in  full  strength. 

Gradually  other  articles  may  be  added,  such  as  crackers,  toast, 
porridge,  rice  pudding,  cornstarch,  junket,  and  blancmange.  Orange 
juice  may  be  taken  freely,  and  an  occasional  baked  apple  with  cream 
or  a  few  stewed  prunes  will  act  favorably  upon  the  bowels. 

It  is  best,  as  in  the  case  of  adults,  to  forbid  meat  broths,  and 
eggs  and  meat  in  any  form  should  be  withheld  for  three  or  four 
weeks  after  the  urine  has  regained  its  normal  composition.  Subse- 
quently a  menu  may  be  composed  from  such  articles  as  a  chop,  the 
breast  of  a  chicken  or  partridge,  a  little  broiled  whitefish,  a  poached 
egg,  oysters,  custard,  a  baked  mealy  potato  with  fresh  butter,  stale 
bread,  wine  jelly  with  cream,  crackers,  boiled  rice  and  cream,  and 
fresh  ripe  fruits. 


ALBUMINTJRIA,  FUNCTIONAL  AND  ORGANIC  547 

ALBUMINURIA,  FUNCTIONAL  AND  ORGANIC 

Pathological  Physiology. —  Albuminuria  may  be  produced  by  al- 
terations in  the  composition  of  the  blood  and  by  structural  or  func- 
tional changes  in  the  kidney  itself,  or  by  both.  The  albumin  is 
derived  from  the  blood  serum,  which  in  turn  comes  from  the  protein 
of  the  food.  Tinder  ordinary  circumstances  protein  in  passing  through 
the  body  undergoes  several  transformations  which  affect  its  degree 
of  solubility  and  its  ability  to  osmose  or  pass  through  animal 
membranes  such  as  line  the  alimentary  canal,  the  blood  vessels,  and 
the  tubules  of  the  kidney.  The  conditions  of  osmosis  also  depend 
in  part  upon  the  relative  density  of  the  fluids  on  either  side  of  the 
membrane,  hence  alterations  in  the  composition  of  the  blood  plasma 
may  permit  the  osmosis  of  serum  albumin  into  the  tubules  of  the 
kidney.  It  is  important  to  observe  that  the  presence  of  serum  al- 
bumin in  the  urine  in  excess  not  only  indicates  a  functional  or  struc- 
tural weakness  in  the  kidneys  themselves,  or  in  the  composition  of 
the  blood,  but  it  represents  actual  loss  of  substance  from  the  body  — 
in  other  words,  there  is  a  leak  of  nutrient  matter  from  the  kidneys. 

It  might  seem  feasible  to  disregard  the  leakage  and  increase  the 
amount  of  proteid  food  sufficiently  to  counterbalance  the  loss  sus- 
tained. The  same  plan  might  theoretically  be  thought  to  be  of 
benefit  in  cases  of  diabetes,  where  it  would  seem  quite  possible  to 
counterbalance  the  loss  of  saccharine  material  from  the  kidneys  by 
ingestion  of  much  larger  quantities  of  starches  and  sugars;  but  this 
is  a  fallacious  comparison,  for  excess  of  sugar  is  really  a  foreign 
body  in  the  blood,  while  albumin  is  not.  Clinically,  moreover,  it  has 
been  found  that  when  either  of  these  conditions  of  loss  of  substance 
through  the  kidneys  exists  it  is  better  to  withhold  as  much  as  pos- 
sible the  particular  variety  of  food  which  is  leaking  through  them  and 
reduce  the  work  of  these  organs. 

Functional  Albuminuria. —  It  is  not  many  years  since  the  detec- 
tion of  albumin  in  the  urine  was  regarded  as  an  infallible  indication 
of  some  form  of  renal  disease,  but'  the  fact  is  now  established  that 
errors  in  diet  and  faulty  assimilation  produced  by  mental  and  nerv- 
ous strain,  overwork,  and  worry,  and  more  particularly  by  the  phe- 
nomena of  very  rapid  growth  in  the  later  years  of  childhood  and 
early  youth,  may  give  rise  to  temporary  or  "  functional  albuminuria." 

A  solution  of  meat  albumin  experimentally  transfused  into  the 
venous  circulation  of  a  dog,  or  injected  either  subcutaneously  or  into 
the  rectum,  reappears  unaltered  in  the  urine,  but  serum  albumin 
similarly  injected  is  retained  by  the  blood  and  does  not  cause  albu- 


548  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

mjnuria,  although  the  percentage  of  albumin  in  the  blood  plasma 
has  been  raised  considerably  above  the  normal.  Moreover,  if  a  man 
in  health  eats  eight  or  ten  raw  eggs  in  the  course  of  five  or  six 
hours,  traces  of  serum  (not  egg)  albumin  may  appear  in  the  urine. 
The  matter  is  of  interest  in  connection  with  the  diet  for  chronic 
Bright's  disease  (p.  551).  Albuminuria  thus  produced  is  merely 
temporary,  and  is  directly  dependent  on  the  nature  of  the  food. 
When  so  much  of  this  proteid  has  been  eaten  a  portion  of  it  is 
absorbed  directly  into  the  blood  without  formation  of  intermediate 
products  of  digestion.  Similarly  this  albumin  may  be  excreted  by 
the  kidney.  But  if  the  digestive  activity  in  the  stomach  is  great, 
a  large  number  of  raw  eggs  may  be  eaten,  and  as  many  as  nineteen 
have  been  taken  in  thirty-six  hours  (Dolradin)  without  the  ap- 
pearance of  albuminuria.  It  is  no  doubt  true  in  such  an  instance, 
as  suggested  by  Yeo,  that  the  vigor  of  digestion  converts  egg  albumen 
into  peptones,  which  finally  form  serum  albumin,  •  whereas  with  a 
slower  digestion  more  is  absorbed  unaltered.  According  to  the  ex- 
periments of  Stokvis,  coagulated  egg  albumen  cannot  be  made  to 
reappear  in  the  urine  of  healthy  animals,  but  raw  egg  albumen  can. 

Oertel  (Therapeutics  of  Circulatory  Derangements,  von  Ziemssen's 
Handbook  of  General  Therapeutics),  as  a  result  of  numerous  experi- 
ments upon  man  and  animals,  in  opposition  to  the  above  view, 
declares  that  "egg  albumen,  given  in  whatever  quantity,  is  not  nor- 
mally excreted  as  such  by  the  kidneys,  and  does  not  cause  albumi- 
nuria." The  albumen  absorbed  is  all  destroyed  in  the  blood  or  tissues 
and  excreted  as  urea  from  the  kidneys.  He  further  says  that  "  a 
great  increase  of  albumen  supplied  to  the  blood  causes  no  increased 
excretion  of  albumen  by  the  kidneys,  and,  in  particular,  that  egg 
albumen  gives  rise  to  no  irritation  of  the  renal  vessels  and  no  albu- 
minuria (nor  does  it  increase  an  existing  albuminuria)."  I  have 
long  been  in  the  habit  of  allowing  eggs  to  be  eaten  in  chronic  cases 
of  nephritis  and  have  never  known  them  to  increase  the  albumin 
output. 

Of  all  the  varieties  of  albuminuria,  those  which  are  most  amen- 
able to  dietetic  treatment  are  the  functional  form  and  that  which 
accompanies  chronic  Bright's  disease.  The  functional  albuminuria 
which  is  produced  by  eating  an  excess  of  protein  or  by  muscular 
fatigue,  which  results  in  the  accumulation  of  large  quantities  of 
nitrogenous  waste  matter  and  interference  with  normal  oxidation 
processes,  is  usually  curable  by  ascertaining  and  removing  the  cause. 

In  the  instance  given  above  of  albuminuria  caused  by  eating  large 
numbers  of  eggs,  it  was  emphasized  that  the  proteid  in  the  urine 


ALBUMINURIA,  FUNCTIONAL  AND  ORGANIC  549 

is  egg  albumen  and  not  serum  albumin.  When  albuminuria  already 
exists,  meat  proteids  will  increase  the  amount  eliminated  by  the  kid- 
neys. 

It  is  probable  that  some  persons  inherit  a  special  weakness  of  the 
kidney  structure  or  an  abnormal  irritability  of  the  renal  cells  which 
favors  the  occurrence  of  albuminuria  from  slight  provocation. 
Granger  Stewart  (Lectures  on  Important  Symptoms  of  Albuminuria) 
states  that  he  has  observed  in  certain  persons  that  cheese,  as  well  as 
eggs,  is  capable  of  producing  temporary  albuminuria. 

In  regard  to  the  production  of  functional  albuminuria  from  die- 
tetic errors  Yeo  argues,  I  think  correctly,  as  follows :  "  May  not 
the  true  explanation  be  that  the  ingestion  of  so  large  an  excess  of 
albuminous  material  may  throw  upon  the  kidneys  such  an  excess 
of  nitrogenous  waste  (to  be  excreted)  that  a  temporary  functional 
hyperaemia  of  the  kidneys  is  excited,  and  that  this  leads  to  a  slight 
escape  of  albumin  from  the  blood?  It  appears  to  us  that  this  is  a 
sound  physiological  explanation  of  what  is  observed  to  occur,  and 
accounts  for  its  occurrence  in  fever  or  disordered  constitution,  and 
not  in  the  perfectly  sound  and  vigorous/' 

Albuminuria  also  results  from  passive  hyperaemia  of  the  vessels  of 
the  kidney,  from  active  congestion  and  inflammation,  irritant  metallic 
poisons,  the  toxins  of  the  exanthemata,  especially  scarlatina  and 
erysipelas  and  those  of  typhus  fever,  diphtheria,  etc.,  all  of  which 
may  prove  highly  irritating  to  the  renal  epithelium. 

Dietetic  Treatment. —  The  frequent  return  of  functional  albumi- 
nuria should  be  regarded  as  an  indication  of  special  weakness  of 
the  kidneys  in  the  same  way  that  frequent  functional  glycosuria  in- 
vites suspicion  of  the  strength  of  the  digestive  power  of  the  liver, 
and  demands  a  careful  regulation  of  the  diet.  Meat  should  be 
forbidden  temporarily,  as  well  as  all  forms  of  alcoholic  drinks  or 
other  substances  liable  to  produce  renal  irritation,  and  the  diet  should 
consist  chiefly  of  fruits,  cereals,  vegetables,  and  milk. 

Attention  should  be  paid  to  increasing  the  activity  of  the  bowels. 

When  functional  albuminuria  is  observed  in  children  and  adoles- 
cents, the  following  dietary,  from  which  a  considerable  variety  of 
foods  may  be  selected,  is  recommended : 

Bacon,  sweetbreads,  custards,  butter,  cream,  milk,  cereals,  and 
breadstuffs,  gingerbread,  potatoes,  beets,  lettuce,  spinach,  string 
beans,  tomatoes,  celery,  blancmange,  Bavarian  cream,  whipped  cream, 
and  sponge  cake,  wine  or  lemon  jelly,  junket,  bread  pudding,  apple 
sauce,  oranges,  ripe  bananas,  pineapple  juice,  prunes,  cocoa,  lemonade, 
orangeade. 


550  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 


Causation. —  Chronic  interstitial  nephritis  may  be  of  primary  origin, 
or  develop  as  a  result  of  arterio-sclerosis  and  other  conditions.  It  is 
usually  a  slow  process,  and  is  often  provoked  by  chronic  alcoholism  and 
chronic  metal  poisoning,  especially  by  lead  and  arsenic.  The  arterial 
walls  are  thickened  and  arterial  tension  is  high.  The  urine  varies 
in  composition  and  quantity,  according  to  the  variety  of  lesions 
present. 

That  an  exclusive  meat  diet  is  not  the  cause  of  chronic  Bright's 
disease  is  proved  by  the  fact  that  Eskimos  and  other  races,  who  sub- 
sist altogether  upon  it,  are  not  especially  liable  to  the  disease,  al- 
though in  the  long  sunless  winter  they  live  under  very  bad  hygienic 
conditions.  (See  the  relation  of  proteid  food  to  albuminuria,  p.  547.) 
It  is  nevertheless  a  fact  that  the  disease  is  very  prevalent  in  this  coun- 
try among  men  past  forty  years  of  age  who  for  years  have  been 
overworked  with  business  cares,  and  who  have  neglected  to  take  suffi- 
cient exercise  and  care  in  eating.  In  all  stages  of  the  disease  much 
may  be  accomplished  by  dietetic  treatment. 

Cooked  meats,  spices  and  highly  seasoned  food  in  general  are  in- 
jurious in  all  cases  of  existing  albuminuria.  The  fluctuations  ob- 
served are  often  due  to  diet  merely,  and  the  albumin  may  be  con- 
siderably reduced  in  quantity,  or  absent  temporarily  from  the  urine, 
although  the  lesion  of  the  kidneys  is  making  uninterrupted  progress. 
The  volume  of  albumin  in  the  urine  should  not,  therefore,  be  regarded 
alone  as  an  indication  for  dietetic  treatment;  it  is  merely  one  of 
many  symptoms  incident  to  the  course  of  chronic  Bright's  disease 
which  are  benefited  by  a  strict  regimen. 

Extensive  disease  of  the  excretory  surface  of  the  kidneys  interferes 
with  the  normal  elimination  of  proteid  waste  which  accumulates  in  the 
system  until  it  finally  produces  toxic  or  uramic  symptoms  of  a  most 
serious  character.  If  the  alimentary  canal  is  overloaded  with  food 
above  the  actual  requirements  of  nutrition,  or  beyond  the  capabilities 
of  the  system  for  oxidizing  certain  food  products,  toxic  symptoms 
follow.  For  these  reasons  the  diet  in  chronic  Bright's  disease  should 
be  regulated  definitely,  and  a  mean  maintained  between  overburden- 
ing the  digestive  apparatus  and  withholding  food  which  is  needed 
to  support  the  bodily  strength.  This  applies  especially  to  proteid 
waste,  which  passes  off  through  the  kidneys,  whereas  the  waste  of 
carbohydrate  food  is  eliminated  from  the  lungs,  in  the  form  of 
water  and  carbonic-acid,  in  water  from  the  kidneys  and  skin,  and  as 
carbonates  and  other  salts  in  the  urine. 


CHRONIC  BRIGHT 'S  DISEASE  551 

Dietetic  Treatment 

It  is  generally  believed  that  meat  is  harmful  in  chronic  nephritis, 
although  it  is  probable  that  the  danger  lies  more  in  the  extractives 
than  in  the  albumin  of  the  meat.  Of  late,  however,  there  has  been 
a  decided  tendency  to  allow  a  more  liberal  dietary  to  the  nephritic, 
depending,  of  course,  upon  the  stage  of  the  disease.  F.  C.  Shattuck 
of  Boston  declares  that  "more  patients  with  recognized  nephritis 
suffer  from  insufficiency  than  excess  of  proteids,"  and  Von  Noorden 
recommends  a  varied  diet  with  reduced  proteid  content,  rather  than 
an  exclusive  milk  diet  for  most  chronic  cases. 

A  purely  vegetable  diet  often  has  been  tried  for  albuminuriacs,  but 
it  causes  too  pronounced  anaemia  if  its  use  is  persisted  in,  and  a 
minimum  of  animal  food  should  therefore  be  prescribed.  Granger 
Stewart  says,  in  speaking  of  the  very  chronic  albuminuria  of  Bright's 
disease,  "  In  the  more  advanced  stages  the  diet  should  be  as  nutritious 
as  possible,  and  then  certainly  fresh  meat  is  by  no  means  injurious." 
AVith  failing  cardiac  compensation  the  heart  muscle  may  give  out 
unless  meat  be  eaten. 

In  the  early  stages,  often  for  a  period  of  several  years,  the  patient 
may  feel  well  and  present  no  symptoms  other  than  the  albuminuria. 
To  withhold  meats  altogether  in  such  instances  may  be  to  induce 
anaemia  and  reduce  the  patient's  strength,  without  corresponding 
gain  in  the  condition  of  the  urine.  My  rule  is  to  allow  such  pa- 
tients, without  anasarca  or  uraemic  symptoms,  to  eat  red  meats  spar- 
ingly, once  or  twice  a  week,  and  sometimes  once  a  day,  but  much 
depends  upon  the  age  of  the  patient,  duration  of  the  nephritis,  the 
existence  of  complicating  diseases,  etc.  With  the  onset  of  any  uraemic 
symptoms  or  of  high  arterial  tension,  headache,  gastric  disturbances, 
etc.,  meat  should  be  withheld,  at  least  temporarily,  and  resort  should 
be  had  to  a  milk  diet  as  in  acute  nephritis.  Chicken,  tongue,  ham, 
fish,  and  eggs  are  forms  of  proteid  food  which,  although  some  of 
them  are  rich  in  proteid  content,  are  less  likely  to  be  eaten  to  excess 
than  beefsteak,  roast  beef  or  mutton. 

Milk  Diet. —  In  many  cases  of  chronic  Bright's  disease  with  ad- 
vanced symptoms,  the  effect  of  feeding  the  patient  for  six  weeks, 
or  even  two  or  three  months,  upon  an  exclusive  milk  diet,  is  remark- 
ably gratifying.  The  quantity  of  urine,  urea,  and  extractives  in- 
creases, while  the  albumin  diminishes,  and  cedema  and  general 
anasarca  disappear.  The  patient's  strength  and  general  condition 
improve,  the  pulse  is  strengthened,  and  if  dyspnoea  pre-existed  it 
subsides. 


552  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

The  quantity  of  milk  to  be  prescribed  for  an  exclusive  milk  diet 
depends  on  the  age  and  size  of  the  patient,  as  well  as-  upon  his 
ability  to  exercise  and  use  force  in  muscular  energy.  If  the  patient 
is  invalided  so  as  to  be  confined  to  his  room  or  the  house,  from  five 
to  seven  pints  of  milk  daily  are  sufficient.  Seven  pints  of  milk 
contain  216  grams  of  albumin  and  casein,  172  grams  of  fat,  and 
161  grams  of  lactose;  whereas,  according  to  Pettenkofer  and  Voit, 
a  healthy  adult  requires  137  grams  of  dry  albumin,  117  grams  of 
fat,  and  352  grams  of  carbohydrates  (see  p.  326).  The  milk  diet  is 
therefore  deficient  in  carbohydrates,  but  the  latter  are  estimated  in 
Voit's  table  for  a  person  taking  active  exercise,  and  requiring  the 
development  of  more  muscular  energy  and  heat  than  the  invalid.  If 
the  patient  lose  weight  on  a  milk  diet,  although  it  otherwise  agrees 
with  him,  it  may  be  well  to  add  farinaceous  food  in  the  shape  of 
rice,  bread,  crackers  and  milk  sugar.  Oranges  also  may  be  eaten. 
Many  patients  live  contentedly  with  no  other  food  than  a  bowl 
of  bread  and  milk  four  or  five  times  a  day.  In  some  cases  it  is  in- 
advisable to  commence  the  milk  diet  immediately,  and  a  good  result 
may  best  be  attained  by  cutting  off  one  article  of  solid  food  after 
another  and  replacing  the  loss  by  an  additional  tumblerful  of  milk. 
Where  it  is  expected  to  employ  a  milk  diet  for  many  weeks,  as  in 
an  advanced  case  of  Bright's  disease,  it  is  usually  found  that  the 
milk  is  better  borne  if  taken  fresh  at  a  natural  temperature  and  with- 
out flavoring  of  any  kind.  Although  the  treatment  may  seem  severe 
at  first,  if  the  patient  understands  the  gravity  of  the  situation  he 
often  is  willing  to  accept  it,  and  after  a  few  days  seldom  com- 
plains of  the  monotony.  In  the  gravest  cases  it  is  desirable  to  give 
the  milk  at  brief  intervals,  in  quantities  of  six  ounces,  once  an  hour 
during  the  daytime,  with  an  extra  tumblerful  at  night,  and  on 
awakening  in  the  morning.  Ordinarily,  however,  it  is  tiresome  to 
have  to  drink  milk  so  often,  and  the  quantity  may  be  so  regulated 
as  to  give  the  requisite  amount  once  every  three  hours.  The  quan- 
tity of  milk  necessary  to  support  life  for  any  length  of  time  and 
maintain  good  nutrition,  especially  if  the  patient  is  exercising  at 
all,  is  considerable,  and  he  should  take  from  twelve  to  fourteen  six- 
ounce  tumblerfuls  of  milk  in  the  twenty-four  hours.  It  is  usually 
impossible  to  commence  at  this  rate  without  producing  gastric  dis- 
turbance from  souring  of  the  milk  in  the  stomach,  and  possibly 
diarrhoea.  The  latter  symptom  is  a  certain  indication  that  the  milk 
is  being  imperfectly  digested,  and  a  temporary  reduction  in  its  quan- 
tity is  advised. 

It  is  very  important  thoroughly  to  cleanse  the  mouth  after  drink- 


CHRONIC  BRIGHT 'S  DISEASE  553 

ing  the  milk,  in  order  to  avoid  coating  the  tongue  and  a  dis- 
agreeable taste  which  destroys  the  appetite  and  interferes  with  the 
efficacy  of  the  treatment.  For  discussion  of  this  subject  see  Milk 
Diet  in  Typhoid  Fever  (p.  474).  Obstinate  constipation,  which  almost 
invariably  results  from  a  milk  diet,  may  be  met  by  medicinal  treat- 
ment, or  enemata.  As  a  rule,  the  milder  laxatives  are  the  only 
remedies  necessary;  a  glass  of  citrate-of-magnesia  solution,  a  half 
tumblerful  of  bitter  water  taken  on  rising  in  the  morning,  a  drachm 
of  the  compound-licorice  powder,  or  a  two-grain  pill  of  extract  of 
cascara  sagrada  at  night,  will  prove  sufficient.  There  is,  however, 
no  objection  in  most  cases  to  allowing  the  use  of  stewed  prunes  or 
the  soft  part  of  two  or  three  baked  apples,  or  the  juice  of  two  or 
three  oranges  in  a  tumblerful  of  Yichy. 

It  will  be  observed  that  whereas  the  normal  average  quantity  of 
urine  for  an  adult  male  is  52  ounces  for  the  twenty-four  hours,  the 
milk  diet  under  discussion  requires  the  ingestion  of  upward  of  80 
ounces  of  fluid.  This  necessitates  increased  activity  of  the  kidneys, 
but  the  polyuria  usually  results  in  the  removal  of  the  anasarca  which 
frequently  exists.  The  body  weight  may  remain  normal,  be  slightly 
increased  or  it  is  not  infrequently  diminished,  much  depending  upon 
the  condition  of  the  patient  at  the  time  when  the  milk  diet  is  in- 
augurated. The  abundant  urine  is  of  a  pale-yellowish  hue,  which 
is  somewhat  typical  of  the  milk  diet.  The  specific  gravity  is  low, 
and  the  reaction  may  be  neutral  or  faintly  acid  on  account  of  the 
dilution.  The  albumin,  which  at  first  may  be  present  in  considerable 
bulk  —  sufficient  when  coagulated  to  almost  solidify  the  contents  of 
the  test  tube  —  gradually  diminishes,  and  the  urea  and  salts  increase. 
In  mild  cases  the  milk  diet  should  be  continued  from  4  to  6  weeks, 
after  which  a  slight  variation  may  be  allowed  in  the  form  of  cereals 
and  fresh  vegetables,  and  fruit.  In  other  cases  it  may  be  neces- 
sary to  prolong  the  treatment  for  several  months,  because  it  will  be 
found  that  any  attempt  to  materially  alter  the  diet  is  followed  by  an 
increase  in  the  albumin  and  dropsy,  with  return  of  other  symptoms. 
In  such  patients  the  lesion  of  the  kidney  is  far  advanced  and  incur- 
able, and  the  most  that  can  be  hoped  for  from  any  treatment  is  an 
amelioration  of  the  gravest  symptoms.  For  the  class  of  cases  in 
which  this  treatment  is  found  for  any  reason  to  be  impracticable, 
either  from  the  persistent  refusal  of  the  patient  to  take  milk  or 
from  any  other  cause,  before  giving  up  its  use  efforts  should  be  made 
to  modify  its  preparation  in  various  ways,  tempting  the  patient  with 
different  flavors  (see  p.  85)  and  with  light  farinaceous  foods,  of 
which  milk  forms  nn  important  basis,  such  as  bread,  crackers,  and 
38 


554:  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

rice  pudding.  Much  milk  may  be  taken  in  very  weak  coffee  or 
tea,  or  in  the  form  of  soups  and  purees  made  with  celery  or  po- 
tatoes, or  gruels  may  be  given,  or  milk  thickened  with  tapioca,  ver- 
micelli, sago,  or  rice,  and  flavored  with  a  very  little  lemon  or  orange 
peel,  cloves,  or  allspice.  It  is  not  desirable  to  use  much  high  season- 
ing for  fear  of  irritating  the  diseased  kidneys. 

As  the  patient  improves,  the  milk  diet  may  be  given  up,  but  not 
too  suddenly.  A  sudden  restriction  of  fluids  in  chronic  nephritis 
is  injurious,  and  their  quantity  should  be  regulated  by  the  vascular 
tension.  In  adopting  any  other  diet  it  is  a  good  rule  never  to  let 
the  proteid  food  bear  a  greater  proportion  to  the  carbohydrate  than 
one  to  four.  The  former  increases  the  proportion  of  urea  in  the 
urine,  the  latter  reduces  it. 

When,  after  a  milk  diet,  the  change  is  to  be  made  to  a  more  liberal 
menu,  the  hours  of  taking  the  milk  may  be  reduced  in  frequency, 
and  some  of  the  milk  may  be  replaced  by  boiled  fish,  chicken,  or 
game,  and  fresh  green  vegetables,  potatoes,  cream,  butter,  eggs,  ham, 
and  bacon.  Cereal  foods  may  be  eaten  ad  libitum,  such  as  hominy, 
corn  bread,  oatmeal,  sago,  tapioca,  rice,  vermicelli,  bread  pudding, 
and  macaroni.  Cheese  may  be  eaten  occasionally.  The  urine  should 
be  periodically  examined,  and  if  it  is  found  that  the  eating  of  meat 
is  followed  by  an  increase  in  the  albuminuria  the  patient  should 
return  to  the  milk  diet. 

It  not  rarely  happens  that  strict  adherence  to  a  milk  diet  for 
several  weeks  produces  more  lasting  improvement  in  the  action  of 
the  kidneys,  so  that  a  diet  to  which  steak,  roast  beef,  chops,  and 
eggs  are  admitted  not  only  may  be  well  borne,  but  may  increase  the 
strength  of  the  patient.  This  is  a  matter  which  obviously  cannot  be 
regulated  by  fixed  rules.  If  the  general  principles  of  the  treatment 
are  understood,  it  is  easy  to  apply  them  to  individuals.  In  cases 
in  which  it  is  found  after  trying  all  methods  that  milk  cannot  be 
assimilated  in  any  form,  the  patient  should  live  upon  a  carbohydrate 
diet,  consisting  of  fresh  vegetables  and  fruits,  with  butter,  cream, 
and  olive  oil.  Dujardin-Beaumetz  allows  pork  and  ham  to  be  eaten 
by  those  who  refuse  to  relinquish  meat  entirely. 

An  exception  to  the  value  of  an  exclusive  milk  diet  exists  in  cases 
in  which,  owing  to  persistent  high  arterial  tension  (chronic  in- 
terstitial nephritis)  the  large  amount  of  fluid  ingested  increases  the 
tension,  and  overtaxes  an  already  hypertrophied  heart.  In  such  cases 
milk  should  be  in  great  part  replaced  by  cereals,  cooked  fruits  and 
green  vegetables. 

Water    Drinking. —  It    was    formerly    taught    that    the    chronic 


CHRONIC  BRIGHT 'S  DISEASE  555 

nephritic  should  drink  as  much  water  as  possible  to  promote  elimina- 
tion of  waste,  and  wash  out  casts  from  the  renal  tubules,  but  several 
writers,  and  notably  Von  Noorden,  have  pointed  out  the  danger  of 
raising  arterial  tension  by  drinking  too  much  fluid,  to  a  point  which 
may  cause  a  breakdown  of  the  compensatory  cardiac  hypertrophy. 
The  quantity  of  water  ingested  should  be  adapted  according  to  the 
individual  case;  thus  patients  having  high  tension  or  anasarca  re- 
quire less  than  those  who  have  merely  a  reduced  output  of  a  con- 
densed urine.  When  there  is  high  tension,  water  should  be  drunk 
from  a  small  wineglass,  rather  than  a  tumbler,  or  sipped,  rather 
than  drunk,  and  taken  at  frequent  intervals.  By  this  means  the 
sudden  strain  upon  the  circulation  of  absorbing  a  large  bulk  of  fluid 
may  be  avoided. 

In  general,  the  patient  had  better  leave  alcohol  alone,  especially 
in  the  form  of  strong  liquors.  If  habituated  to  its  use,  a  feeling  of 
dullness  and  drowsiness  after  a  glass  of  wine  is  a  strong  reason  for 
giving  it  up.  Tea,  coffee,  and  cocoa  are  permissible  during  intervals 
of  betterment. 

The  effect  of  dietetic  treatment  will  be  much  enhanced  by  securing 
systematic  outdoor  exercise,  and  freedom  from  worry  and  anxiety, 
and  particular  attention  should  be  paid  to  keeping  the  bowels  open, 
for  which  laxative  fruits  may  be  taken  freely.  The  patient  should 
be  cautioned  against  overeating,  and  all  food  should  be  masticated 
thoroughly. 

SUMMARY  OF  DIET  FOR  THE  CHRONIC  NEPHRITIC 

(Without  Anasarca,  or  Other  Grave  Symptoms,  Either  Digestive  or 
Circulatory,  and  urith  Fairly  Good  Urine)  : 

Meats:  Bacon,  ham,  sweetbread,  tripe,  tongue,  liver,  chicken  (oc- 
casionally). A  chop  or  thin  slice  of  rare  beef  two  or  three  times  a 
week. 

Milk,  butter,  buttermilk,  cheese,  cream,  eggs  in  any  form,  custards. 

Fish  of  any  kind. 

Cereals  and  farinaceous  foods,  especially  bread,  shredded  wheat, 
hominy,  cornmeal,  puffed  rice,  boiled  rice,  macaroni,  spaghetti, 
wheaten  grits,  wheatena. 

Vegetables:  Potatoes  both  white  and  sweet,  beets,  new  peas, 
corn,  string,  Lima,  or  butter  beans,  tomatoes,  celery,  lettuce, 
spinach,  cauliflower,  Brussels  sprouts,  eggplant,  cucumbers,  onions, 
carrots. 

Gelatins:     Plain  blancmange,  chocolate  blancmange,  fruit  jellies. 

Fruits:     Apples    in    any    form,    oranges,    peaches,    pears,    plums, 


556  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

prunes,  grapes,  berries  of  any  kind  (except  cranberries)  ripe  bananas, 
pineapple  juice,  nectarines,  apricots,  melons. 

Beverages:  Weak  tea,  cocoa,  and  exceptionally,  cafe  au  lait. 
Koumiss. 

Forbidden  Foods:  Condiments,  spices,  pickles,  all  red  meat  (ex- 
cept as  specified  above),  fried  foods,  rich  sauces,  gravies,  potted  or 
devilled  meats,  dried,  salted,  canned  or  preserved  foods,  beef  juice, 
meat  extracts  or  essence,  pastry,  cake,  confectionery,  sweets  of  all 
kinds  (as  being  liable  to  cause  dyspepsia). 

DIET  FOB  CHRONIC  PARENCHYMATOUS  NEPHRITIS  WITH  GENERAL 
ANASARCA SALT-FREE  DIET. 

A  "  salt-free  "  or  "  declorinated  "  diet  lately  has  been  recommended 
to  promote  absorption  in  chronic  parenchymatous  nephritis,  pleurisy 
with  effusion,  anasarca  from  any  cause,  ascites,  and  all  cases  of  ex- 
tensive serous  effusion.  The  treatment  is  certainly  not  new,  having 
been  described  in  the  Hindu  medical  work,  the  Charaka,  compiled 
1,000  years  B.  C.  The  treatment  has  been  endorsed  by  Widal, 
Strauss  and  Eumpf  and  in  this  country  by  J.  L.  Miller  of  Chicago, 
G.  L.  Peabody  of  New  York,  and  others.  The  normal  salt  require- 
ment in  health  is  from  15  to  30  grains  per  diem  (Bruge)  but  the 
majority  of  persons  consume  much  more  —  usually  y±  to  1/2  oz.  In 
the  salt-free  diet  foods  are  chosen  which  contain  a  minimum  of 
inorganic  salts,  and  no  table  salt  at  all  is  added  in  cooking,  or  eaten 
as  a  condiment.  In  detail  this  diet  consists  of  milk,  eggs,  butter, 
chicken,  bread  made  without  salt,  cereals  cooked  without  salt,  fruits, 
jellies,  tea,  coffee. 

Peabody  reports  (N.  Y.  Med.  Eecord,  March  9,  1907)  several 
obstinate  cases  of  general  anasarca  which  were  temporarily  much 
benefited  by  this  diet.  In  some  cases  it  undoubtedly  lessens  oedema 
and  anasarca,  but  my  personal  experience  has  not  been  to  realize 
all  that  is  claimed  for  it.  It  does  no  harm,  and  is  worth  trying. 

PYELITIS 

Most  cases  require  abundant  fluid,  such  as  alkaline  mineral  wa- 
ters, for  the  purpose  of  washing  out  the  pelvis  of  the  kidney,  and 
if  there  is  much  irritation  or  painful  micturition,  it  is  well  for  the 
patient  to  be  put  on  an  exclusive  milk  diet  after  the  manner  de- 
scribed above  for  treatment  of  nephritis  in  the  preceding  section. 
The  foods  especially  to  be  avoided  are  also  mentioned  in  the  section 
on  nephritis. 


OXALURIA  557 

OXALURIA 

The  condition  of  oxaluria  may  be  unsuspected  by  the  patient,  or 
it  may  attract  his  attention  by  a  sensation  of  burning  in  the  urethra, 
desire  for  frequent  micturition,  headache,  "  nervousness,"  etc. 

Causation. —  The  occasional  presence  of  a  trace  of  calcium  oxa- 
late  in  the  urine  need  not  be  considered  as  abnormal,  but  the  con- 
tinued presence  of  this  substance  in  excess  is  mainly  caused  by  eat- 
ing certain  kinds  of  food  and  by  dyspepsia  and  perverted  nutrition, 
involving  incomplete  oxidation  in  the  system  of  amylaceous,  saccha- 
rine, and  fatty  foods. 

Ellis  says  that  "  oxalic  acid  is  very  readily  prepared  in  the  chemical 
laboratory  by  the  action  of  reagents  upon  sugar,  starch,  and  cellulose. 
This  fact  would  seem  to  render  probable  the  possibility  of  its  forma- 
tion from  the  imperfect  oxidation  of  these  substances  in  the  body." 
Mugge  has  shown  that  bacteria  can  form  this  acid,  and  its  crys- 
tals occur  in  the  intestine  and  are  found  in  the  feces.  Oxaluria 
is  common  in  connection  with  dyspepsia,  and  it  is  not  improbable 
that  some  of  it  may  be  derived  from  imperfect  digestion  of  food  in 
the  intestine,  and  be  absorbed  into  the  blood  just  as  ptomaines  are. 

Cantani  finds  that  oxaluria  is  frequently  present  among  those 
who  indulge  too  freely  in  saccharine  and  amylaceous  foods.  Beneke 
holds  quite  an  opposite  theory,  and  attributes  the  condition  to  im- 
perfect metabolism  of  proteids.  Fasting  animals  may  show  traces  of 
calcic  oxalate  in  their  urine,  and  both  increased  and  diminished  oxi- 
dation have  been  held  accountable  for  oxaluria. 

Vegetables  and  fruits  containing  oxalic  acid  and  its  salts,  and 
which  may  cause  oxaluria  when  eaten  in  excess,  are  rhubarb,  toma- 
toes, turnips,  onions,  sorrel,  spinach,  figs,  strawberries,  apples,  pears. 
Many  other  fruits  and  vegetables  contain  traces  of  oxalic  acid,  but 
this  fact  is  of  little  or  no  dietetic  importance.  Eaw  fruits  and  vege- 
tables which  contain  citric,  malic,  and  other  organic  acids  seem  to 
bear  close  relation  to  the  formation  of  oxalic  acid.  The  latter  is 
not  necessarily  ingested  with  the  food,  but  is  produced  in  the  body 
from  a  variety  of  food  substances. 

Dietetic  Treatment. —  The  diet  should  consist  of  such  animal 
food  only  as  eggs,  fish,  and  poultry  —  with  cereals,  stale  bread  or 
toast  and  a  minimum  of  butter.  Tea,  coffee,  carbonic-acid  water,  and 
alcohol  should  be  forbidden  temporarily.  Hot  water  (three-quarters 
of  a  pint)  should  be  sipped  half  an  hour  before  each  meal,  and  before 
breakfast  a  drachm  or  more  of  Carlsbad  salts  may  be  taken  in  con- 
stipated cases.  Dilute  mineral  acids,  hydrochloric  or  nitro-hydro- 


558  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

chloric,  are  beneficial  if  taken  immediately  after  meals  in  doses  of 
fifteen  or  twenty  minims  in  water. 


CALCULI,  RENAL  AND  VESICAL 

The  treatment  of  calculi  involves  discussion  of  beverages  and  foods.  r 

Beverages. —  When  the  presence  of  vesical  calculus  has  been  demon- 
strated it  becomes  important  to  regulate  the  diet  so  as  to  prevent, 
if  possible,  increase  of  the  trouble.  Not  much  is  to  be  hoped 
from  the  action  of  any  solvents,  such  as  the  alkaline  waters  or  lithia 
salts,  upon  a  large  stone  already  formed,  but  diuretics  may  certainly 
do  much  to  prevent  recurrence  of  the  formation  by  controlling  vesical 
catarrh.  As  White  observes :  "  Our  object  should  then  be  to  make 
the  urine  as  bland  and  abundant  as  possible,  and  for  this  purpose 
there  is  nothing  better  than  milk  and  the  free  use  of  water  between 
meals.  The  particular  kind  of  water  to  be  used  is  of  minor  im- 
portance, as  the  most  noted  waters  in  the  treatment  of  stone  seem 
to  have  purity  as  their  chief  recommendation." 

The  milk  is  soothing,  and  while  it  is  a  good  diuretic,  it  lessens  the 
desire  for  frequent  micturition  which  is  often  such  an  annoying  symp- 
tom of  vesical  stone. 

The  still  spring  waters,  such  as  Poland,  Londonderry,  or  Bed- 
ford, may  be  prescribed,  or  the  waters  of  Vichy,  Saratoga,  or  Ems, 
on  the  principle  that  many  patients  will  drink  more  fluid  which 
bears  the  name  of  some  reputed  "  Spring "  than  they  will  if  it  be 
plain  water. 

The  occurrence  of  vesical  calculus  in  children  is  believed  by 
Cadge,  White,  and  others  to  be  directly  proportional  to  the  diffi- 
culty of  getting  good  milk.  It  is  therefore  commoner  among  the 
children  of  the  poor.  White  believes  that  "  diet  and  regimen,  at 
least  in  cities,  have  much  more  to  do  with  the  production  of  stone 
than  heredity,  climate,  water,  etc." 

Young  infants  should  not  be  given  lime  water  indefinitely  with 
their  milk. 

It  is  best  for  adults  to  relinquish  the  use  of  alcoholic  stimulants, 
but  if  this  is  not  feasible  light  Ehine  wine  or  still  Moselle  is  ad- 
missible, especially  if  neutralized  by  some  alkaline  table  water.  Lager 
beer  is  not  harmful,  and  a  little  dry  champagne  or  a  light  hock  or 
white  wine  may  be  taken.  All  the  heavier  clarets,  Burgundy  and 
sweet  wines  of  every  sort,  port,  sherry,  ale,  porter,  and  stout  are 
forbidden.  Weak  tea  and  coffee  may  be  drunk  sweetened  with 
saccharin.  Only  such  beverages  should  be  allowed  as  contain  no 


LITH^EMIA  —  URIC-ACID  DIATHESIS  —  GRAVEL        559 

free  acids  and  no  sugar,  and  those  having  the  greatest  diuretic  effect 
are  the  best. 

Foods. —  All  highly  seasoned  and  irritating  articles,  like  vinegar, 
pickles,  strong  condiments,  such  as  mustard,  should  be  forbidden, 
AS  well  as  anything  prone  to  excite  acid^  dyspepsia. 

Among  patients  who  have  calculi  of  various  kinds  a  considerable 
number  are  at  the  same  time  afflicted  with  obesity.  Such  persons 
should  be  especially  abstemious  in  regard  to  the  use  of  fats  and 
sugars.  Less  corpulent  persons  may  be  allowed  a  little  more  laxity 
in  this  regard.  Other  substances  to  be  avoided  are  puddings  made 
with  eggs  and  sugar,  suet  puddings,  pastry  of  all  kinds,  meat  fat, 
and  fat  pork. 

Bread,  oatmeal,  hominy,  cracked  wheat,  cornmeal  bread,  custards, 
blancmange,  boiled  fish,  and  eggs  are  all  admissible. 

In  cases  of  uric  acid  calculi  total  abstinence  from  animal  food  for 
three  or  four  weeks  is  followed  by  marked  improvement,  the  patient 
living  meanwhile  on  green  vegetables,  salads,  and  cooked  fruits 
-which  are  not  too  acid,  such  as  apples,  not  sweetened,  but  flavored 
with  some  bland  aromatic,  like  cinnamon,  nutmeg,  or  cloves.  In 
other  cases  it  may  not  be  necessary  to  withhold  meat  completely, 
but  it  should  be  taken  in  moderation,  not  more  than  once  a  day,  and 
it  should  be  rare,  lean,  and  thoroughly  masticated.  White  meat  of 
chicken  may  be  eaten. 

The  Carlsbad  dietary,  in  which  butter  and  sugar  in  all  forms  are 
rigidly  proscribed,  is  found  to  benefit  calculus  cases  more  than  the 
total  withdrawal  of  meat. 

The  above  general  directions  apply  to  the  treatment  of  most  va- 
rieties of  calculi,  but  should  be  modified  from  time  to  time  to  suit 
particular  cases. 

In  elderly  subjects,  in  whom  calculi  are  relatively  common,  the 
functional  elimination  of  waste  from  the  body  is  considerably  im- 
paired. For  such  persons,  as  well  as  for  those  who  live  sedentary 
lives,  it  is  important  to  abstain  from  overeating  and  especially  from 
the  use  of  animal  food  in  excess. 

LITH^EMIA  —  URIC-ACID  DIATHESIS  —  GRAVEL 

Symptoms. —  Lithaemia  is  a  vague  condition  in  which  the  system 
contains  an  excess  of  uric  acid  or  its  salts,  and  is  usually  productive 
of  such  symptoms  as  insomnia,  vertigo,  tinnitus  aurium,  disagreeable 
fullness  of  the  head,  and  general  "  nervousness."  The  urine  becomes 
loaded  with  nitrogenous  waste.  It  is  uncertain  how  much  harm  is 


560  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

due  to  uric  acid  itself,  and  how  much  to  autotoxins  formed  in  the 
intestines  or  tissues  as  an  accompanying  process. 

When  uric  acid  appears  in  excess  as  a  sediment  in  the  urine  it 
is  desirable  that  its  formation  be  checked,  if  possible,  and  that  any 
crystals  already  deposited  in  the  kidneys  and  bladder  should  be 
dissolved  and  eliminated.  If  the  accumulation  continues,  the  pres- 
ence of  crystals  ("  gravel ")  gives  rise  to  attacks  of  ureteral  or 
vesical  colic,  causing  agonizing  pain,  and  often  haBmaturia.  A  ma- 
jority of  the  different  forms  of  calculi  are  composed  wholly  or  in 
part  of  uric  acid,  and  they  may  be  formed  in  any  part  of  the  urinary 
system,  which,  in  addition  to  the  other  symptoms,  may  possibly 
cause  ulceration  and  inflammation  of  the  mucous  membrane  or 
serious  obstruction  to  the  outflow  of  the  urine.  The  exact  mode  of 
production  of  uric  acid  in  the  body  is  still  a  matter  of  uncertainty, 
but  it  is  associated  with  proteid  katabolism.  Nucleins  are  derived 
by  digestion  from  peculiar  nucleo-proteids  which  are  contained  chiefly 
in  the  thymus  gland,  liver,  and  spleen,  but  also  in  slight  proportion 
in  meat  and  meat  extracts,  and  they  appear  to  be  at  least  one  of  the 
principal  sources  of  uric-acid  formation.  Tea,  coffee,  and  cocoa  are 
believed  to  aid  in  the  process  of  uric-acid  formation  in  some  manner 
in  the  body,  whereas  milk  and  eggs  do  not  have  that  effect.  The 
final  destination  of  uric  acid  is  its  conversion  into  urea,  but  from 
lack  of  perfect  oxidation  this  process  is  checked. 

Dietetic  Treatment. —  The  indications  for  dietetic  treatment  are, 
therefore,  to  reduce  the  animal  foods  in  amount  or  temporarily  with- 
hold them  altogether,  while  giving  large  quantities  of  plain  water 
and  of  waters  containing  potassium  or  lithium  salts  to  aid  in  dis- 
solving the  uric  acid  already  existing  in  the  kidneys  or  bladder. 

Although  the  acidity  of  the  urine  is  not  caused  by  uric  acid,  but 
by  acid  sodium  phosphate  (Na2P04),  the  deposition  of  uric  acid  is 
accomplished  in  an  acid  menstruum,  and  it  is  well  to  reduce  the 
urine  temporarily  to  a  neutral  or  somewhat  alkaline  reaction. 

Animal  food,  except  milk,  tends  to  make  the  urine  acid,  whereas 
milk  and  vegetable  food  favor  alkalinity.  In  speaking  of  the  lithic- 
acid  diathesis  in  children,  J.  M.  Fothergill  wrote  that  "  lean  meat,  raw 
meat  minced,  and  beef  tea  are  so  much  poison."  Lithsmic  head- 
aches will  often  cease  Avhen  the  patient  stops  eating  butcher's  meat, 
cheese,  etc.,  if  excessive  indulgence  in  animal  food  has  been  the 
previous  habit.  Meat  extracts  are  worse,  for  the  dyspepsia  which 
often  accompanies  litha?mia  is  a  conservative  process,  checking  the 
digestion  of  animal  foods,  whereas  the  predigested  foods  are  more 
promptly  and  easily  carried  to  the  overburdened  liver.  Some  li- 


LITHJEMIA  —  TRIG- ACID  DIATHESIS  —  GRAVEL        561 

thaemis  patients  cannot  take  meat  well  in  hot  weather,  but  can  do  so 
at  other  seasons.  An  excessive  meat  diet  cannot  be  regarded  as  the 
sole  cause  of  lithaemia;  other  factors  are  concerned,  such  as  over- 
eating and  the  abuse  of  saccharine  food,  which  causes  malfermenta- 
tion,  deranges  the  functions  of  the  liver,  and  alters  the  composition 
of  both  blood  and  urine. 

Murchison  long  ago  declared  that  "  habitual  lithasmia  often  results 
from  the  patient  taking  more  food  than  can  be  converted  into  tissue 
or  disintegrated  in  the  liver,"  and  Sir  Henry  Thompson  expressed 
his  .views  in  regard  to  sweets  thus  forcibly :  "  Sugar,  in  all  its  forms, 
at  every  meal,  and  wherever  met  with,  forbid  it  altogether,  .  .  . 
let  fatty  matters,  butter,  cream,  and  the  fat  of  meat,  whether  simply 
cooked  or  in  combination  to  form  pastry,  be  taken  very  sparingly." 
This  is  the  practice  at  Carlsbad  also,  and  it  reduces  the  work  of 
the  liver  and  kidneys.  For  some  patients  —  especially  the  obese  —  it 
is  more  important  than  entirely  eliminating  meat  from  the  regimen. 

Murchison,  who  was  among  the  first  to  advocate  a  rational  dietetic 
treatment  of  habitual  lithaemia,  forbade  all  saccharine  and  oleaginous 
food,  especially  "made  dishes,"  and  highly  seasoned  foods,  sauces, 
rich  gravies,  etc.  In  serious  cases  he  advised  giving  up  amylaceous 
foods  as  well,  and  forbade  the  eating  of  potatoes,  rice,  sago,  fruits, 
etc.,  and  bread  was  allowed  only  in  moderation. 

Many  acids  contained  in  fresh  fruits,  such  as  benzoic  or  quinic 
acid,  have  a  favorable  solvent  action.  These  acids  are  found  in  the 
external  cuticle  of  fresh  fruits  and  vegetables,  which  may  be  eaten 
in  cases  of  lithsemia.  According  to  the  late  Dr.  Lyman  of  Chicago, 
eating  raw,  unpeeled  apples  in  considerable  quantities  supplies  potas- 
sium salts,  which  tend  to  increase  the  alkalinity  of  the  blood,  but 
sweet  fruits,  pears,  grapes,  plums,  strawberries,  etc.,  may  not  be 
indulged  in. 

Patients  may  eat  abundantly  of  oatmeal,  wheaten  and  Graham 
bread  toasted,  macaroni,  fresh  young  peas,  string  beans,  Lima  beans, 
rice,  spinach,  asparagus,  eggplant,  celery,  lettuce  and  other  salads, 
except  tomato  (without  oil).  Meat  should  not  be  eaten  oftener  than 
twice  a  week.  Fresh  fish,  sweetbread,  poultry,  and  game  may  be 
taken  sparingly.  No  diet  should  be  strictly  enforced  in  every  case 
alike.  Alexander  Haig  (Diet  and  Food)  classifies  as  "uric-acid- 
free  "  foods,  milk  and  its  products,  breadstuffs,  cereals  and  glutens, 
nuts,  vegetables,  and  fruits. 

If  lithaemia  is  present  in  young  children  after  three  or  five  years 
of  age,  they  require  a  larger  proportion  of  fat.  They  may  have  bread 
and  butter  with  a  little  fat  bacon,  or  a  baked  potato  with  butter,  and 


562  DIET  IN  DISEASES  OF  THE  URINARY  SYSTEM 

puddings  of  bread,  crackers,  rice,  or  sago,  but  not  of  raw  flour.  They 
should  not  be  offered  sweets.  They  have  poor  appetites,  and  variety 
ought  to  be  prescribed,  or  they  will  lose  weight  and  strength. 

The  cooking  is  as  important  as  the  composition  of  the  food. 

Beverages. —  Various  alkaline  mineral  waters  are  constantly  pre- 
scribed for  adults,  and  patients  who  can  afford  to  take  the  course 
are'  benefited  by  the  waters  of  Vichy  $  Evian,  Neuenahr,  Ems,  etc., 
but  for  those  to  whom  travel  is  an  impossibility  and  whose  means 
do  not  allow  them  to  purchase  artificial  mineral  waters,  very  good 
substitutes  are  to  be  made  by  dissolving  sodium  carbonate  or  sodium 
phosphate  in  soda  water  or  sour  lemonade,  or  in  plain  water,  in 
the  proportion  of  from  one  to  two  drachms  in  three  or  four  pints, 
to  be  taken  in  the  course  of  the  twenty-four  hours,  or  two  to  five 
grains  of  the  carbonate  of  lithium  may  be  employed  in  the  same 
•way.  Waukesha,  Londonderry,  and  Buffalo  lithia  waters  are  also 
used,  but  it  may  be  said  of  most  so-called  lithia  waters  that  their 
use  is  chiefly  that  of  pure  water,  for  a  barrelful  would  have  to  be 
drunk  to  obtain  an  ordinary  medicinal  dose  of  lithium. 

Most  patients  do  better  without  alcohol  in  any  form.  They  may 
feel  the  loss  of  accustomed  stimulation,  but  they  should  make  a 
strong  effort  to  give  it  up  completely.  Malt  liquors  and  sweet  wines, 
champagne,  and  spirits  had  better  be  forbidden  absolutely.  A  little 
good,  sound  claret  or  Scotch  whisky  in  water  is  the  least  harmful 
drink. 

Gravel  is  much  less  common  among  habitual  beer  drinkers  than 
among  those  whose  daily  beverage  is  wine.  This  is  attributed  by 
Moleschott  to  the  greater  acidity  and  larger  proportion  of  alcohol 
in  the  latter.  On  the  contrary,  Ebstein  holds  that  beer  is  not  in- 
jurious in  lithiasis,  and  tea  has  some  reputation  in  checking  the 
deposition  of  uric  acid.  Coffee  does  no  harm. 

Important  adjuncts  to  dietetic  treatment  are  exercise  to  the  de- 
gree of  inducing  free  perspiration,  Turkish  or  electric  light  baths, 
and  an  open  air  life. 

GONORRHOEA 

The  dietetic  treatment  of  gonorrhoea  consists  in  avoiding  all  al- 
cohol and  stimulating  food  and  drinking  bland  diluents. 

In  severe  cases,  and  in  cases  among  young  children  who  have  in 
some  manner  been  infected,  a  skimmed-milk  diet  should  be  ordered 
at  first.  Later,  light  farinaceous  articles,  stale  bread  and  butter, 
milk,  and  rice  puddings  should  be  added.  Patients,  for  fear  of  at- 


DIET  IN  ABNORMAL  DENTITION  563 

tracting  attention  to  their  ailment,  are  often  unwilling  to  restrict 
their  meals,  but  they,  should  avoid  acid  fruits,  red  meats,  all  highly 
seasoned  and  fried  food,  pickles,  condiments,  and  pastry.  Alcoholic 
drinks  in  all  forms  are  absolutely  prohibited.  Malt  liquors  are  espe- 
cially bad,  as  they  are  in  all  diseases  of  the  urethra,  bladder,  or  pros- 
tate. No  late  meals  should  be  taken.  By  observing  these  directions 
troublesome  chordee  and  ardor  urinae,  so  liable  to  appear  in  the  first 
fortnight,  may  be  prevented.  Large  quantities  of  such  waters  as 
soda,  Seltzer,  Apollinaris,  besides  two  quarts  of  plain  water  should 
be  drunk  daily.  The  fluid  dilutes  the  urine,  diminishes  the  danger 
of  cystitis,  and  has  the  additional  advantage  of  decreasing  the  appe- 
tite. 

DIET  IN  DISEASES  OF  THE  ALIMENTARY  CANAL 

DISEASES  OF  THE  STOMACH 

DIET  IN  ABNORMAL  DENTITION 

In  abnormal  dentition  in  children  the  food  is  imperfectly  masti- 
cated, and  gastric  dyspepsia  or  gastric  catarrh  may  follow.  If  den- 
tition is  delayed  and  the  teeth  are  imperfect,  as  in  the  case  of  rickets, 
scrofula,  tuberculosis,  or  any  protracted  disease  involving  nutrition, 
the  diet  should  be  made  as  nourishing  as  possible,  and  meat,  eggs, 
milk,  cream,  and  broths  should  be  given  in  addition  to  cereals.  Cod- 
liver  oil  is  usually  prescribed  with  benefit.  There  is  no  one  food 
of  special  value  for  retarded  dentition  on  account  of  its  containing 
the  lime  salts  of  the  teeth,  and  the  chief  reliance  for  this  purpose  is 
to  be  placed  upon  building  up  general  nutrition. 

In  all  cases  of  dyspepsia,  gastric  catarrh,  rickets,  or  syphilis  the 
teeth  should  be  examined  carefully  before  prescribing  special  dietetic 
treatment. 

If  the  teeth  are  broken  or  irregular  all  solid  food  should  be  pre- 
pared by  mincing  or  otherwise  reducing  it  to  a  form  requiring  but 
little  mastication.  In  a  young  child  a  sore  mouth  from  swollen  gums 
is  often  overlooked  as  a  cause  of  anorexia. 

The  perfection  with  which  false  teeth  are  now  fitted  has  done 
much  to  improve  the  digestion  of  adults  and  to  add  to  the  comfort 
and,  no  doubt  in  some  instances,  prolong  the  life  of  the  aged.  Their 
use  enables  meats  and  other  solid  food  to  be  eaten,  and  the  act  of 
mastication  increases  the  flow  of  saliva,  which  not  only  digests  starchy 
food  but  tends  to  neutralize  a  too  acid  gastric  juice,  if  the  latter  be 
present. 


564  DIET  IN  DISEASES  OF  ALIMENTARY  CANAL 

STOMATITIS 

Catarrhal  stomatitis  is  a  simple  inflammation  of  the  mucous  mem- 
brane of  the  mouth  which,  among  other  causes,  may  be  excited  by 
taking  food  or  drink  at  either  extreme  of  temperature.  Food  which 
is  very  acid  or  too  highly  seasoned  with  condiments  may  cause  it,  so 
also  may  excessive  drinking  and  smoking. 

No  special  diet  is  required  beyond  food  which  is  easily  swallowed 
and  which  is. free  from  the  above  objections. 

When  the  disease  arises  in  infants  their  diet  may  be  regulated 
.  according  to  the  directions  for  feeding  detailed  under  the  heading 
Infant  Feeding. 

In  gangrenous  stomatitis  the  mouth  may  become  too  sore  to  ad- 
mit of  swallowing,  in  which  case  food  should  be  given  by  the  rectum. 
(See  Nutrient  Enemata,  p.  455.)  Otherwise  small  quantities  of  fluid 
food  should  be  ordered  at  frequent  intervals.  Concentrated  meat 
broths,  egg  albumen,  meat  juice,  and  milk  are  to  be  taken  at  hourly 
intervals.  If  the  stomach  is  irritable  the  food  should  all  be  pre- 
digested  with  pancreatin. 

The  above  directions  apply  also  to  cases  of  inflammation  of  the 
mouth  and  pharynx  caused  by  corrosive  poison,  such  as  carbolic  acid, 
ammonia,  etc. 

TONSILITIS  AND  QUINSY 

These  diseases  require  no  special  care  in  the  acute  stage  beyond 
giving  food  in  such  fluid  form  as  may  be  swallowed  most  easily.  The 
pain  caused  by  this  act  is  often  so  extreme  that  it  is  advisable  to 
concentrate  all  food,  to  lessen  the  number  of  necessary  acts  of  deglu- 
tition. Meat  juice,  peptonoids,  and  beaten  eggs,  may  be  added  to 
good  milk.  Junket  and  custards  are  easy  to  swallow.  Plain  vanilla 
ice  cream  may  be  given;  its  coldness  is  sometimes  soothing  to  the 
pharynx. 

Holding  cracked  ice  in  the  mouth  before  swallowing  will  some- 
times annul  the  pain  momentarily,  or  in  extreme  cases  the  pharynx 
and  tonsils  may  be  sprayed  with  cocaine,  and  the  period  of  tempo- 
rary anaesthesia  may  be  utilized  for  swallowing  considerable  nourish- 
ment. This  is  rarely  necessary,  for  unless  the  patient  is  emaciated 
by  previous  serious  illness,  he  is  not  likely  to  be  in  need  of  much 
food  for  a  day  or  two.  In  serious  cases  of  suppurative  tonsilitis 
the  strength  suffers  more,  and  stimulants  may  be  given  by  the  rectum 
if  deglutition  bo  impossible. 


DYSPHAGIA  565 

After  all  forms  of  tonsilitis  there  is  often  considerable  anaemia, 
and  the  patient  for  a  week  or  two  should  eat  abundantly  of  animal 
food.  Eggnog  and  milk  punches  may  be  needed  for  the  first  few 
days  of  convalescence  from  quinsy. 

DYSPHAGIA 

When  the  normal  mechanism  of  swallowing  the  food  is  disturbed 
the  condition  is  called  dysphagia.  It  is  commonly  due  to  one  of  the 
following  causes :  Spasm  of  the  muscles  of  mastication  (trismus) ; 
inflammations  of  the  mouth,  tongue,  pharynx,  or  tonsils;  diphtheria; 
tubercular,  cancerous,  or  syphilitic  pharyngeal  disease;  retropharyn- 
geal  abscess;  stricture  or  carcinoma  of  the  oesophagus;  pressure  from 
new  growths  external  to  the  oesophagus;  paralyses  (sometimes  of 
central  origin)  ;  operations  upon  or  near  the  pharynx;  or  the  wearing 
of  an  O'Dwyer  intubation  tube  in  the  larynx. 

The  devices  employed  to  enable  the  patient  to  overcome  pain  or 
difficulty  in  swallowing  should  include  reduction  of  the  efforts  at 
swallowing  to  a  minimum.  A  raw  egg  or  oyster  may  sometimes  be 
gulped  down  by  a  single  act  when  the  dread  of  pain  from  more 
repeated  effort  deters  the  patient  from  taking  other  food.  Whatever 
is  given  should  consist  therefore  of  concentrated  nutriment  in  a 
smooth,  semisolid  or  gelatinous  form.  Wine  jelly  may  be  re-enforced 
with  beef  peptonoids,  beef  meal,  or  egg  albumen,  and  custards  may 
be  thickened  with  farinaceous  material  to  a  consistence  which  will 
enable  them  to  be  swallowed  quickly.  Milk  or  cream  toast  may  be 
prescribed. 

When  patients  are  unable  to  swallow,  an  cesophageal  tube  is  in- 
serted for  feeding,  which,  however,  should  be  a  catheter  of  small 
caliber  (English  8  to  18),  and  which  need  not  be  passed  very  far 
down  into  the  oesophagus.  If  necessary,  a  2-  or  4-per-cent  solution 
of  cocaine  may  be  applied  first  to  the  pharynx  to  relieve  pain  and 
irritation.  The  fluid  food  —  eggnog,  broths,  thick  gruels,  milk, 
cream,  etc. —  is  poured  into  the  tube  through  a  funnel. 

When  tube  feeding  cannot  be  practiced,  it  becomes  necessary  to 
resort  to  rectal  enemata,  or  both  methods  may  be  employed  in  order 
to  reduce  the  number  of  feedings  through  the  painful  throat. 

D.  B.  Delavan  calls  attention  to  the  important  fact  that  the  point 
of  greatest  irritation  is  often  the  palatine  arches,  and  by  passing  the 
tube  through  the  nose  into  the  pharynx  behind  them  this  difficulty 
is  neatly  avoided. 

In  hopeless   cases  of  cancerous   or   tubercular  ulceration   of   the 


566  DIET  IN  DISEASES  OF  ALIMENTARY  CANAL 

epiglottis,  tonsils,  etc.,  which  are  intensely  painful,  it  may  be  justifi- 
able to  perform  gastrotomy  in  order  to  place  food  directly  in  the 
stomach.  This  is  certainly  preferable  to  letting  the  patient  starve 
to  death  because  he  finds  the  agony  of  swallowing  is  worse  than 
the  pangs  of  hunger. 

STRICTURE  AND  CARCINOMA  OF  THE  OESOPHAGUS 

In  diseases  of  the  oesophagus  which  render  swallowing  difficult  all 
food  should  be  given  in  semisolid  or  fluid  form.  Many  vegetable 
substances  may  be  made  in  purees,  which  may  be  strengthened  by 
meat  juice,  meat  extracts,  or  beef  meal.  Milk  junket  or  cream  in 
various  forms,  is  always  soothing,  and  may  be  the  only  food  which 
the  patient. can  take. 

Eichardson  states  that  in  cesophageal  stricture  cold  food  relaxes 
the  circular  fibers  of  the  oesophagus  and  dilates  its  lumen,  whereas 
hot  food  has  an  opposite  effect.  In  some  nervous  patients  this 
may  prove  true,  but  in  most  cases  of  genuine  stricture  or  occlusion 
the  temperature  of  the  ingested  food  makes  little  difference.  When 
the  occlusion  or  the  difficulty  or  pain  in  deglutition  becomes  so  great 
that  the  patient  suffers  from  inanition  —  as,  for  example,  after  cor- 
rosive poisons  have  been  swallowed  —  he  should  be  fed  by  nutrient 
enemata.  Should  the  trouble  not  be  overcome,  a  gastric  fistula  may 
be  made. 

Feeding  Through  a  Gastric  Fistula. —  When  a  gastric  fistula  is 
made  the  wound  may  be  left  open  with  a  drainage  tube,  or,  what 
is  better,  a  permanent  hard-rubber  or  metallic  tube  is  inserted,  having- 
a  double  flange,  like  a  spool.  The  tube,  if  metal,  is  nickel-plated 
to  prevent  erosion  by  the  acid  gastric  juice.  The  lumen  may  be  a 
third  of  an  inch  in  diameter,  and  when  not  in  use  it  is  kept  closed 
by  a  cork.  When  the  patient  is  to  be  fed  he  lies  upon  his  back. 
The  cork  is  removed,  the  tube  cleansed  with  a  syringeful  of  warm 
water,  and  through  a  glass  funnel,  to  which  is  attached  an  inch  or 
two  of  rubber  tubing,  fluid  food  and  water  is  poured  directly  through 
the  fistulous  opening  into  the  stomach.  If  desirable,  lavage  may  be 
performed  in  a  similar  manner.  Any  kind  of  food  may  be  given 
which  the  patient  is  able  to  digest.  Even  small  pieces  of  chopped 
meat  may  be  pushed  into  the  stomach  with  a  glass  rod  or  forceps. 
Medicines  are  conveniently  given  through  the  same  opening.  When 
the  fistula  lias  been  made  for  other  cause  than  malignant  disease  the 
tube  may  bo  worn  indefinitely  with  no  other  inconvenience  than  that 
attending  the  peculiar  process  of  feeding.  I  have  seen  several  pa- 


FOREIGN  BODIES  SWALLOWED  567 

tients  who  have  worn  such  tubes  for  years,  and  who  go  about  like 
other  men,  excepting  that  they  take  their  meals  in  private  and  feed 
themselves  while  lying  on  the  back.  One  of  these  patients,  who  was 
operated  upon  in  Bellevue  Hospital  by  F.  S.  Dennis  for  a  benign 
stricture  of  the  pylorus  following  typhoid  fever  (an  extremely  rare 
lesion),  first  masticates  his  food,  then  expectorates  it  and  pushes  it 
into  the  tube  with  a  glass  rod.  He  maintains  robust  health  and  on 
one  occasion  returned  to  the  hospital  in  a  state  of  hilarious  inebriety, 
having  fed  himself  the  greater  part  of  a  quart  bottle  of  whiskey 
through  his  funnel. 

In  some  cases  the  use  of  the  tube  may  be  discarded,  the  opening 
into  the  stomach  being  automatically  closed  by  a  flap-like  valve  of 
tissue. 

FOREIGN  BODIES  SWALLOWED 

When  foreign  bodies  have  been  accidentally  swallowed,  such  as 
coins,  buttons,  safety  or  other  pins,  large  cherry,  plum,  or  other 
fruit  stones,  fish  bones,  chicken  bones,  or  pieces  of  clam  or  oyster 
shells,  if  the  patient  is  seen  within  two  or  three  hours,  the  object 
having  passed  beyond  the  reach  of  the  finger  or  cesophageal  probang, 
an  emetic  may  be  given.  If  this  fail  to  return  the  foreign  body  from 
the  stomach,  the  patient  should  eat  large  quantities  of  bread,  oat- 
meal, or  potatoes.  The  plan  of  this  treatment  is  to  furnish  a  bulk 
of  fecal  matter,  which  in  the  intestines  may  envelop  the  pin  or  bone, 
and  prevent  its  sharp  or  roughened  ends  from  injuring  the  mucous 
membrane.  Three  hours  later  a  dose  of  castor  oil  should  be  given. 
By  this  means  many  dangerous  objects  may  be  voided  safely.  If 
the  foreign  body  does  not  appear  after  the  oil  has  acted,  the  treat- 
ment should  be  repeated  next  day,  and  the  stools  watched  until  it 
is  recovered.  Experience  has  shown  that  the  search  should  not  be 
abandoned  for  at  least  eight  or  ten  days.  Men  who  earn  a  precarious 
livelihood  by  publicly  exhibiting  themselves  as  possessing  "  iron 
stomachs,"  and  who  swallow  broken  glass,  coins,  nails,  etc.,  take  con- 
siderable risk  from  exciting  grave  injury  or  peritonitis,  but  by  eating 
the  foreign  bodies  only  when  the  stomach  is  nearly  full,  and  by 
following  the  treatment  outlined  above,  they  manage  to  escape 
death. 

The  insane,  imbeciles,  and  idiots,  often  swallow  foreign  bodies  of 
various  kinds,  the  former  sometimes  with  suicidal  intent.  Pins, 
needles,  fragments  of  broken  china  and  other  sharp  bodies  are  some- 
times used  for  this  purpose. 


568  DIET  IN  DISEASES  OF  THE  STOMACH 

INDIGESTION  AND  DYSPEPSIA 

Symptoms. —  Indigestion  and  dyspepsia  are  terms  which  refer  essen- 
tially to  functional  slight  and  often  temporary  derangement  of  the 
digestive  system,  although  these  conditions  may  result  from  many 
varieties  of  disease,  especially  from  fever  due  to  almost  any  cause. 
The  terms  are  used  somewhat  vaguely  to  include  a  number  of  minor 
symptoms,  such  as  weight  and  oppression  at  the  epigastrium  and 
prsecordium,  eructations,  "water  brash,"  palpitations,  vertigo,  head- 
ache, modified  taste  and  thirst  sensations,  loss  of  appetite  or  morbid 
craving  for  certain  indigestible  articles  of  food,  flatulency,  hiccough, 
and  sometimes  nausea,  heartburn,  pain  referred  to  the  cardiac  end  of 
the  stomach,  lassitude,  irritability,  drowsiness  or  restlessness,  and 
despondency.  As  Sir  Henry  Thompson  said :  "  The  word  indiges- 
tion denotes  not  a  disease,  but  an  admonition." 

The  late  J.  M.  Fothergill  wrote:  "If  it  were  not  for  the  pro- 
tection of  indigestion,  of  which  many  so  bitterly  and  ungratefully 
complain,  the  lives  of  a  large  number  of  individuals  would  not  at- 
tain their  furthest  potential  expansion." 

Many  of  these  symptoms,  especially  those  referable  to  the  nervous 
and  vascular  systems,  are  due  to  the  fact  that  morbid  products  which 
closely  resemble  poisonous  alkaloids  in  their  action  (as  indeed  in 
their  composition),  are  easily  absorbed,  and  produce  effects  varying 
in  intensity  from  slight  headache  to  the  collapse  of  violent  ptomaine 
poisoning  (p.  421).  Other  symptoms  are  doubtless  due  to  imper- 
fect elimination  of  waste  matter  of  food  or  "  ashes  "  from  the  system. 

Bauer  says :  "  It  is  beyond  doubt  that  insufficient  secretion  is  the 
essential  cause  of  most  dyspeptic  symptoms  as  they  appear  in  various 
disorders  of  the  stomach." 

In  severe  fevers  and  conditions  of  advanced  anasmia  or  gastric 
catarrh  the  stomach  secretes  chiefly  a  ropy  alkaline  mucous  fluid, 
with  little  or  no  true  gastric  juice. 

As  a  rule,  the  acid  gives  out  before  the  pepsin,  and  a  deficiency 
of  acid  is  a  very  common  condition,  especially  in  anaemia.  Anaemia 
produced  experimentally  by  repeated  bleeding  of  animals  will  cause 
it.  Chronic  hypera?mia  and  inflammation  of  the  stomach  excited  by* 
coarse  irritating  food  have  the  same  result,  and  the  free  acid,  if  se- 
creted, is  neutralized  by  abundant  mucus. 

Deficiency  of  hydrochloric  acid  in  the  gastric  juice  has  a  three- 
fold effect:  1,  Failure  to  digest  proteids;  2,  failure  to  arrest  mal- 
fermentation  or  putrefactive  changes  in  the  food;  3,  failure  to  excite 
gastric  peristalsis,  so  that  the  food  lingers  too  long  in  the  stomach. 


INDIGESTION  AND  DYSPEPSIA  569 

Other  causes  of  delay  may  be  found  in  too  large  a  bulk  of  food, 
lack  of  peristalsis,  and  obstruction  through  stenosis  of  the  pylorus 
without  corresponding  increase  in  contractile  power  of  the  stomach. 

Gases. —  The  normal  gases  of  the  stomach  are  those  of  atmospheric 
air;  but  food  which  is  improperly  fermenting  is  capable  of  evolving 
others,  and  those  which  have  been  determined  by  analysis  of  eructa- 
tions are  C02,  H2,  02,  N2,  CH4  (marsh  gas)  C2H4  (olefiant  gas). 
Karl  Emil  Ewald  reported  a  case  in  which  sufficient  marsh  gas  was 
evolved  from  the  stomach  to  be  collected  and  ignited  and  burn  with 
a  pale-yellow  flame. 

Some  degree  of  lactic-acid  fermentation  may  be  a  normal  accom- 
paniment of  gastric  digestion,  but  the  process  is  easily  carried  too 
far;  butyric  acid  develops,  and  gases  are  evolved.  This  action  re- 
sembles that  produced  outside  the  body  when  decomposing  albumin 
comes  in  contact  with  saccharine  substances. 

Distention  of  the  stomach  and  intestine  with  gas  interferes  with 
the  free  play  of  the  diaphragm  in  the  respiratory  movements,  and 
since  the  heart  lies .  upon  its  side,  separated  from  the  stomach  only 
by  the  diaphragm,  an  inflated  stomach  compresses  and  displaces  the 
heart,  interfering  with  its  rhythm  and  force  and  causing  palpitations. 
The  latter,  in  connection  with  impeded  extent  of  movement  of  the 
diaphragm,  produces  dyspnoea,  especially  on  exertion. 

Pain  is  a  very  frequent  accompaniment  of  dyspepsia.  It  is  usually 
of  a  dull  aching  variety,  but  is  sometimes  sharp  and  acute.  It  is 
often  erroneously  referred  to  the  heart,  but  is  due  rather  to  hyper- 
aesthesia  of  the  stomach  wall,  excited  by  products  of  imperfect  di- 
gestion. 

In  all  diseases  of  the  stomach  the  prolonged  retention  of  any 
particles  of  undigested  food  gives  rise  to  irritation  and  malfermenta- 
tion,  which  still,  further  complicates  the  diseased  condition  of  the 
organ  itself  and  interferes  with  its  proper  action  upon  fresh  quan- 
tities of  food.  This  occasionally  may  be  relieved  by  vomiting  or  by 
the  ingestion  of  some  simple  fluid  which  will  aid  in  washing  the 
stomach  contents  onward  into  the  intestine. 

Etiology. —  Idiosyncrasies. —  Personal  idiosyncrasy  is  a  very  potent 
factor  in  dyspepsia.  Xot  only  do  individuals  vary  from  one  another 
in  this  regard,  but  the  same  person  varies  at  different  periods,  in 
different  stages  of  health,  or  at  different  ages.  One  not  uncom- 
monly observes  persons  who  are  confirmed  dyspeptics  at  home, 
but  who  when  at  sea  are  able  to  eat  and  digest  all  manner  of  richly 
cooked  and  thoroughly  indigestible  food  without  either  nausea  or 
discomfort,  only  to  return  to  their  dyspepsia  on  shore.  On  the  other 


570  DIET  IN  DISEASES  OF  THE  STOMACH 

hand,  many  whose  digestion  is  normal  at  home  are  made  constipated 
and  dyspeptic  by  lack  of  exercise  and  other  conditions  at  sea,  even 
though  they  be  never  "  seasick."  How  often  do  dyspeptics  who  have 
been  kept  long  upon  a  strict  regimen  break  away  from  all  restraint 
and  give  astonishing  accounts  of  the  forbidden  articles  which  they 
have  suddenly  discovered  they  can  eat  for  a  time  with  impunity! 
One  who  cannot  digest  the  most  tender  mouthful  of  prepared  meat 
or  a  crust  of  dry  bread  will  thrive  upon  enormous  quantities  of  nuts 
and  oranges;  another  requires  a  preposterous  quantity  of  pickles  or 
of  Cayenne  pepper  to  stimulate  the  sluggish  digestion  into  any  sort 
of  activity,  and  another  lives  largely  upon  raw  apples ! 

Many  persons  cannot  eat  strawberries  without  attacks  of  heart- 
burn, dyspepsia,  and  angina,  while  for  others  they  are  very  whole- 
some food.  Some  persons  cannot  eat  cauliflower  without  exciting 
dyspepsia,  and  for  others  the  use  of  melted  butter  invariably  brings 
on  such  an  attack,  while  butter  spread  upon  bread  does  not.  Others 
exhibit  intolerance  for  twice-cooked  meats,  new  bread,  potatoes,  sweet 
jams  of  any  kind,  etc.  (See  Idiosyncrasies  in  Eegard  to  Food, 
p.  438.) 

Other  Causes. —  Fats  and  greasy  foods  set  up  butyric-acid  fermenta- 
tion which  causes  heartburn,  regurgitation,  and  a  rancid  disagreeable 
taste. 

Sweets  and  raw  or  insufficiently  cooked  starches  cause  lactic-acid 
and  other  fermentations,  with  flatulence. 

Combinations  of  certain  foods  almost  always  disagree,  as,  for 
example,  sweets  and  acids,  fruits  and  beer,  ice  cream  and  beer,  milk 
and  cherries,  milk  and  crabs. 

Dyspepsia  is  often  caused  by  the  continued  abuse  of  irritants,  such 
as  alcohol  and  highly  seasoned  food,  pickles,  mustard,  Cayenne. 

Tobacco,  strong  tea  and  coffee  have  a  depressing  action  upon  the 
nervous  force  of  the  stomach. 

To  enumerate  all  the  various  substances  which  may  at  some  time 
or  other  cause  indigestion  would  be  to  include  practically  the  entire 
list  of  foods,  a  fact  which  explains  many  of  the  conflicting  dietetic 
rules  which  are  didactically  formulated  by  would-be  authorities. 
Each  new  case  should  be  studied  separately,  and  general  rules  admit 
of  many  exceptions. 

Balfour  concisely  sums  up  the  relations  of  food  to  enfeebled  stom- 
ach digestion  by  saying :  "  Three  things  greatly  disturb  gastric  com- 
fort—  too  large  a  meal,  too  short  an  interval  between  the  meals, 
and,  lastly,  the  ingestion  of  food  into  a  stomach  still  digesting." 

Examination  of  the  Patient. —  It  is  important  at  the  outset  to 


INDIGESTION  AND  DYSPEPSIA  571 

understand  all  the  patient's  habits  of  daily  life,  the  amount  of  sleep 
and  exercise  taken,  the  hours  of  meals  and  quantity  and  quality  of 
food  eaten,  habits  of  drinking  or  smoking,  the  habit  of  the  bowels, 
condition  of  the  urine  and  stools,  and  the  nature  of  any  irregularity 
such  as  the  habit  of  eating  too  fast  or  taking  too  much  or  too  little 
fluid  with  the  meals.  The  condition  of  the  teeth  and  tongue  and 
breath  should  be  observed  also,  and  in  obscure  cases  the  possible  ex- 
istence of  sources  of  reflex  irritation,  like  ovarian  disease,  investigated. 
Proper  cooking  should  be  insisted  upon.  Thorough  cross-examina- 
tion in  regard  to  all  of  these  conditions  may  reveal  habits  not  sus- 
pected by  the  patient  to  be  injurious,  and  which  easily  may  be  cor- 
rected. 

Slow  Eating. —  A  simple  explanation  of  the  normal  physiology  of 
digestion  will  often  interest  an  intelligent  patient  and  secure  his 
hearty  co-operation  in  methods  suggested  for  his  cure,  which  other- 
wise he  would  find  extremely  irksome.  He  should  understand  that 
digestion  commences  at  once  in  the  mouth  by  the  proper  preparation 
there  of  all  food  and  the  digestion  of  starch  in  particular,  and  that 
the  practice  of  slow  eating  gives  time  not  only  for  more  thorough 
mastication,  but  also  for  more  abundant  secretion  of  the  necessary 
digestive  fluids,  saliva,  and  gastric  juice.  Very  slow  eaters  are  far 
less  often  dyspeptic  than  those  who  "  eat  and  run."  The  sign 
"  Quick  Lunch,"  so  commonly  displayed  in  restaurants  in  business 
quarters  of  active  American  cities,  has  contributed  much  toward  earn- 
ing for  Americans  the  title  of  a  "  Nation  of  Dyspeptics,"  for  a  meal 
quickly  served  is  too  quickly  eaten  as  well.  A  dyspeptic  child  should 
be  taught  to  count  between  his  mouthfuls. 

Solid  food  insufficiently  masticated  passes  into  the  stomach  too 
dry  and  in  too  large  masses  for  the  gastric  juice  to  act  upon  it 
promptly,  and  stomach  digestion  is  greatly  retarded.  In  persons 
with  feeble  digestive  power  who  eat  hastily,  pieces  of  meat  and 
tough  vegetable  fibers  often  appear  in  the  stools  unaltered.  The 
sense  of  taste  may  be  utilized  in  order  to  prolong  mastication,  by 
savory  cooking.  It  also  stimulates  the  secretion  of  saliva  and  gastric 
juice.  In  such  cases,  as  well  as  in  those  in  which  the  teeth  are 
absent  or  defective,  it  is  well  to  prohibit  all  food  which  is  not  com- 
pletely subdivided  or  tender,  as,  for  example,  tough  meats  and  stringy 
or  fibrous  vegetables.  (See  "  Fletcherism,"  p.  384.) 

Pain. —  In  nervous  dyspepsia  pain  exists  as  a  prominent  symptom, 
and  is  often  independent  of  the  quality  of  the  food  —  even  a  mouth- 
ful of  water  may  cause  it,  but,  as  a  rule,  fatty  and  acid  foods  excite 
it,  and  therefore  should  be  avoided.  The  appetite,  too,  varies  greatly 


572  DIET  IN  DISEASES  OF  THE  STOMACH 

—  it  may  completely  fail  at  one  time,  and  return  in  an  exaggerated 
form  at  another.  Decker  reported  the  case  of  a  patient  who  was  uni- 
formly awakened  from  sleep  by  such  excessive  hunger  that  he  was 
obliged  to  take  a  hearty  luncheon  in  the  middle  of  the  night.  Such 
patients  usually  secrete  an  excess  of  hydrochloric  acid  in  the  gastric 
juice. 

Examination  of  the  Stomach  Contents 

In  all  cases  of  protracted  dyspepsia  which  do  not  yield  readily 
to  dietetic  treatment  and  proper  medication  it  becomes  important  to 
ascertain  the  exact  condition  of  the  stomach  and  gastric  juice,  and 
for  this  purpose  several  ingenious  clinical  tests  have  been  devised. 
These  tests  are  applied  to  ascertain  —  1.  The  degree  of  acidity  of  the 
gastric  juice.  2.  The  vigor  of  peristaltic  action  of  the  stomach  wall. 
3.  The  rate  of  absorption  from  the  mucous  membrane. 

To  determine  the  acidity  of  the  gastric  juice,  a  fresh  specimen  of 
an  ounce  or  two  should  be  obtained  for  analysis,  and  the  best  method 
is  by  siphonage.  The  stomach  tube  is  inserted  in  the  manner  de- 
scribed for  gastric  lavage  (p.  598.) 

Some  hysterical  dyspeptics  vomit  so  readily  that  the  gastric  juice 
may  be  obtained  from  the  ejecta  at  any  time. 

Test  Meals 

The  composition  of  the  gastric  juice  is  determined  by  following 
lavage  by  a  test  meal.  After  a  definite  period  the  stomach  tube  is 
again  introduced  and  a  sample  of  the  stomach  contents  withdrawn, 
filtered,  and  examined  for  hydrochloric  acid  and  pepsin.  If  desired, 
other  tests  may  be  made  for  rennet  ferment,  carbohydrates,  peptones, 
albuminoses,  lactic  acid,  phosphates,  and  fatty  acids.  The  test  for 
hydrochloric  acid  is  the  one  commonly  applied  for  clinical  purposes, 
and  to  aid  the  selection  of  proper  diet;  the  others  belong  rather 
to  special  research. 

The  best  test  meals  are  Eiegel  and  Leube's  test  dinner,  and  a 
modification  of  this,  known  as  Ewald's  test  breakfast,  which  is  easier 
to  eat  and  does  not  obstruct  the  stomach  tube,  although  it  stimu- 
lates the  digestive  activity  of  the  stomach  somewhat  less.  The  stom- 
ach contents  should  be  withdrawn  for  examination  one  hour  after 
the  test  breakfast,  but  between  four  and  five  hours  after  the  dinner. 

Riegel  and  Leube's  test  dinner  consists  of:  Beef  soup,  400  c.  c. ; 
beefsteak.  200  c.  c. :  white  bread,  50  c.  c. ;  water,  200  c.  c. 

Ewald's  test  breakfast  is  35  to  70  c.  c.  of  wheaten  bread  (one  or 
two  whito  coffee  rolls)  with  300  c.  c.  (10  ozs.)  of  water  or  weak  tea 


INDIGESTION  AND  DYSPEPSIA  573 

without  sugar  or  milk.  When  the  contents  of  the  stomach  are  with- 
drawn one  hour  after  ingestion  of  this  meal  its  total  quantity  should  be 
found  reduced  to  20  to  40  cubic  centimeters,  or  an  average  of  one 
ounce. 

Dujardin-Beaumetz'  test  breakfast  consists  of  coffee  or  tea  with 
milk  and  a  little  sugar,  and  one  or  two  plain  rolls;  no  butter.  The 
fluid  should  not  exceed  a  pint.  The  normal  stomach  digests  such  a 
meal  without  sensation.  If  within  two  hours  there  is  a  sensation  of 
heat  in  the  stomach  or  burning  and  acidity,  hyperacidity  is  present. 
If  there  is  eructation  of  gas,  fullness  and  weight  at  the  stomach,  there 
is  diminished  or  hypoacidity. 

If  pain  occurs  within  fifteen  minutes  with  increasing  intensity  there 
is  probably  some  organic  lesion.  In  hyperacidity,  moreover,  the  burn- 
ing is  worse  three  to  four  hours  after  eating,  and  is  commonest  in  the 
middle  of  the  night.  It  is  often  relieved  by  ingestion  of  food,  which 
temporarily  dilutes  the  acid.  He  urges  dyspeptics  to  sleep  on  the 
right  side,  to  aid  the  passage  of  food  through  the  then  dependent 
pylorus. 

Boas'  test  breakfast  consists  of  an  ounce  of  rolled  oats  boiled  in  a 
quart  of  water  to  a  pint,  and  salted.  The  absence  of  lactic  acid 
makes  this  a  useful  meal  when  it  is  desired  to  test  the  presence  of  that 
acid  in  the  stomach.  Various  combination  meals  are  also  used  to  test 
the  combined  proteolytic  and  amylolytic  power  of  the  gastric  juice. 
A  sample  meal  of  this  sort  contains  bread,  rice,  eggs,  and  meat  with  a 
glass  of  milk. 

In  withdrawing  the  contents  of  a  stomach  after  a  test  meal  the 
same  tube  is  used  (Xo.  23,  A),  and  in  the  same  manner  as  that  em- 
ployed for  lavage,  described  on  p.  598.  It  is  important  that  its  intro- 
duction should  not  be  accompanied  by  violent  retching,  for  when  this 
takes  place  bile  is  liable  to  be  regurgitated  into  the  stomach  and  neu- 
tralize its  acid  contents,  rendering  subsequent  tests  useless.  The 
retching  may  be  overcome  by  painting  or  spraying  the  pharynx  with 
a  2-  or  4-per-cent  solution  of  cocaine,  or,  as  Stewart  recommends, 
by  allowing  the  patient  to  swallow  a  few  drops  of  the  solution,  to 
anesthetize  the  oesophagus.  The  use  of  a  rather  stiff  tube,  quickly 
inserted,  diminishes  the  liability  to  retching.  The  tube  should  not 
be  lubricated  when  used  for  the  test  meals,  but  it  should  be  wetted. 
The  gastric  contents  may  be  forced  out  through  the  tube  by  direct- 
ing the  patient  to  forcibly  expire,  thereby  compressing  the  stomach 
by  the  abdominal  muscles,  and  simultaneously  the  epigastrium  should 
be  firmly  compressed  by  the  hands.  It  is  also  obtained  by  attaching 
to  the  stomach  tube  the  bulb  of  a  Davidson  syringe.  If  no  fluid  flows, 


574  DIET  IN  DISEASES  OF  THE  STOMACH 

a  little  air  or  warm  water  may  be  forced  through  the  tube  to  cleanse 
the  obstructed  fenestra. 

Test  for  Total  Acidity  of  the  Gastric  Juice. —  Before  testing  for 
the  presence  of  free  hydrochloric  acid,  the  total  acidity  of  the  stomach 
may  be  obtained,  which  is  the  combined  acidity  produced  by  HC1 
and  lactic  or  other  organic  acids  commonly  developed  by  malfermenta- 
tion.  This  total  acidity  should  equal  normally  40  to  65  units,  which 
represents  the  number  of  cubic  centimeters  of  test  solution  required 
to  neutralize  exactly  100  cubic  centimeters  of  gastric  filtrate.  The 
test  solution  is  prepared  as  follows : 

"  Four  grams  of  NaOH  dissolved  in  one  liter  of  distilled  water 
are  used  for  neutralization ;  each  cubic  centimeter  of  this  solution  will 
exactly  neutralize  0.00365  grams  of  absolute  hydrochloric  acid.  The 
number  of  cubic  centimeters  so  used  multiplied  by  0.00365  equals  the 
percentage  of  HC1  contained  in  100  cubic  centimeters  of  the  gastric 
filtrate"  (D.  D.  Stewart). 

Chemical  Tests  for  Free  Hydrochloric  Acid. —  A  number  of  chemical 
tests  have  been  devised  for  the  detection  of  hydrochloric  acid. 

Gunzlerg's  Test  for  Free  Hydrochloric  Acid. —  Phloroglucin,  2  gs. ; 
vanillin,  1  g. ;  absolute  alcohol,  30  gs.  Mix. 

Two  or  three  drops  of  this  solution  are  placed  on  a  white  por- 
celain dish  and  allowed  to  flow  slowly  in  contact  with  a  similar 
quantity  of  filtered  gastric  juice.  The  dish  is  very  slowly  and  gently 
heated  over  a  spirit  flame  or  Bunsen  burner,  and  if  hydrochloric  acid 
is  present,  a  faint  rose-red  hue  appears  at  the  line  of  contact,  which 
deepens  as  evaporation  continues  into  a  brilliant  cherry  red.  If  the 
acid  is  abundant,  minute  cherry-colored  crystals  will  form.  If  the 
acid  is  feeble,  it  is  best  to  concentrate  the  stomach  filtrate  upon  a  water 
or  sand  bath  to  about  one-tenth  of  its  original  bulk.  When  merely  a 
faint  trace  of  the  free  acid  is  present  the  appearance  of  the  color 
should  be  watched  carefully,  for  it  is  very  evanescent. 

Giinzberg  showed  that  one  drop  of  the  normal  gastric  juice  —  i.  e., 
juice  containing  0.2  per  cent  of  free  hydrochloric  acid  —  when  diluted 
ten  times,  should  still  give  the -color.  If  it  appears  when  the  dilu- 
tion is  carried  beyond  this  limit,  hyperacidity  is  present. 

The  Boas  Test  for  Free  Hydrochloric  Acid  is  performed  in  a  sim- 
ilar manner  to  the  Giinzberg  test,  but  the  color  produced  varies  from 
rose  to  vermilion,  and  the  solution  is  made  as  follows:  Sublimed 
resorcin,  5  gs. ;  sugar,  3  gs. ;  dilute  alcohol,  100  gs.  Mix. 

Both  tests  are  only  of  value  from  a  positive  standpoint  —  i.  e.,  if 
the  color  reaction  occurs,  free  hydrochloric  acid  surely  is  present. 
They  are,  however,  of  little  or  no  value  as  negative  tests,  for  the  reason 


INDIGESTION  AND  DYSPEPSIA  575 

that  if  peptones  or  certain  other  substances  are  present  in  the  stomach 
contents  the  reaction  may  be  obscured  entirely.  The  latter  difficulty 
is  met  by  application  of  the  calcium-carbonate  test,  which  is  uninflu- 
enced by  other  substances  likely  to  be  associated  with  the  gastric  juice, 
with  the  single  exception  of  an  excess  of  acid  phosphates. 

The  Calcium-carbonate  test  is  conducted  as  follows:  A  sample  of 
gastric  contents  is  heated  to  remove  fatty  acids,  and  shaken  with 
ether  to  remove  any  lactic  acid  present,  and  blue  litmus  paper  is 
dipped  in  the  fluid.  Another  blue  litmus  paper  is  dipped  in  a  fresh 
sample  of  the  gastric  contents  which  has  been  neutralized  by  the  addi- 
tion of  dry  pure  CaC03.  The  redness  of  the  first  paper  when  com- 
pared with  the  second  will  declare  the  presence  of  free  hydrochloric 
acid.  A  strong  Giinzberg  reaction  usually  indicates  normal  reaction 
or  hyperacidity.  Its  absence  when  hydrochloric  acid  is  revealed  by 
the  CaC03  test  indicates  subacidity.  If  the  latter  test  fails,  then  no 
free  acid  is  present.  If  the  litmus  dipped  into  the  gastric  juice  neu- 
tralized by  CaC03  is  reddened,  the  presence  of  acid  salts  (phosphates) 
is  indicated. 

Sahli's  test  for  free  hydrochloric  acid  is  qualitative,  not  quantita- 
tive. It  is  most  ingenious,  and  has  the  advantage  that  it  does  not 
require  the  passage  of  a  stomach  tube.  It  is  performed  as  follows: 
One  grain  each  of  powdered  iodoform  and  methylene  blue  are  placed 
upon  a  small  piece  of  thin  dental  rubber  dam,  not  over  an  inch 
square.  The  ends  of  the  square  are  then  gathered  together  so  as 
to  make  a  tiny  bag,  and  firmly  tied  with  a  piece  of  crude  (not 
sterilized)  catgut.  The  bag,  which  is  about  the  size  of  a  large  pea, 
is  then  swallowed  by  the  patient  immediately  after  a  meal.  If  no 
free  hydrochloric  acid  be  present  the  bag  passes  on  and  is  voided 
unopened  with  the  stools,  for  the  catgut  with  which  it  is  tied  is  not 
dissolved  in  a  neutral  or  alkaline  medium.  If,  however,  free  hydro- 
chloric acid  and  a  little  pepsin  be  present,  the  catgut  dissolves,  liberat- 
ing the  contents  of  the  bag.  The  patient's  urine  is  examined  in  about 
six  hours  and  again  in  twelve  hours,  and  it  will  be  found  to  be  stained 
bright  blue  by  the  aniline,  and  also  to  give  an  iodine  reaction.  In  a 
number  of  cases  in  which  I  have  tried  it,  the  test  has  given  a  uni- 
formly positive  result,  but  in  one  case  of  carcinoma,  the  patient  hav- 
ing died  three  weeks  later,  the  autopsy  showed  that  the  small  piece  of 
gutta  percha  was  still  retained,  and  acted  like  a  valve,  lying  over  the 
greatly  narrowed  pyloric  orifice! 

The  normal  gastric  free  hydrochloric  acid  maintains  a  remarkable 
uniformity  in  maximum  strength,  rarely  exceeding  0.2  per  cent. 

It  has  been  shown  bv  Ewakl  and  Leo  that  it  is  not  secreted  dur- 


576  DIET  IN  DISEASES  OF  THE  STOMACH 

ing  fasting,  but  enters  the  stomach  as  soon  as  the  stimulus  of  food 
is  felt.  At  first  it  replaces  the  acids  from  lactates  and  phosphates, 
setting  these  acids  free  and  forming  chlorides  with  their  bases.  The 
hydrochloric  acid  also  unites  with  albuminoids.  For  these  reasons 
free  HC1  is  not  apparent  in  the  gastric  juice  until  the  combinations 
mentioned  have  all  been  saturated,  after  which  it  increases  in  strength 
to  the  normal  standard  of  0.15  to  0.2  per  cent.  If  alkalies  are  in- 
gested, more  HC1  is  secreted;  but  if  acid  be  taken,  the  further  secre- 
tion of  HC1  is  checked,  so  that  the  average  strength  is  preserved. 

These  conditions  explain  why  it  is  that  within  fifteen  minutes  after 
ingestion  of  an  Ewald  test  breakfast  lactic  acid  may  be  found  in  the 
stomach  contents,  whereas  free  HC1  may  not  appear  for  half  or  three- 
fourths  of  an  hour. 

This  is  an  observation  of  considerable  practical  importance;  for 
in  the  early  stage  of  digestion,  the  acidity  being  low  and  due  only  to 
organic  acid,  the  ptyalin  digestion  of  starches  still  continues,  but  it 
must  cease  as  soon  as  any  appreciable  quantity  of  HC1  is  present. 

Free  hydrochloric  acid  checks  further  development  of  organic  acids, 
such  as  butyric,  acetic,  or  lactic.  The  Bacilli  acidi  lactici  fail  to  act 
in  its  presence,  and  other  bacilli,  like  those  of  typhoid  fever  and  chol- 
era, are  destroyed  by  the  antiseptic  action  of  the  HC1. 

Hypersecretion. —  Hypersecretion  of  gastric  juice  is  determined  by 
withdrawing  the  contents  of  the  stomach  in  the  morning  after  lavage 
the  previous  evening.  If  more  than  50  c.  c.  are  obtained,  hypersecre- 
tion  may  be  said  to  exist,  the  exact  nature  of  which  is  to  be  determined 
by  the  Giinzberg  test  (p.  574).  Suggestions 'for  the  diet  of  such  cases 
are  given  on  p.  584. 

Gastric  Atony. —  Gastric  atony  is  determined  by  finding  in  the 
morning  washings  of  the  stomach  undigested  particles  of  food  eaten 
the  night  before.  The  microscopic  examination  of  the  washings  will 
exhibit  bacteria,  sarcinas,  and  saccharomyces.  The  treatment  of  this 
condition  is  given  under  Chronic  Gastric  Catarrh  (p.  590)  and  Dila- 
tation of  the  Stomach  (p.  597). 

Test  for  Pepsin. —  The  presence  of  pepsin  may  be  determined  by 
digesting  either  egg  albumen  or  blood  fibrin,  the  latter  being  preferred. 
The  fibrin  is  whipped  from  fresh  beef  blood  and  washed  in  water  until 
it  becomes  white.  A  small  piece  is  placed  in  a  test  tube  with  15  or 
20  c.  c.  of  filtered  gastric  juice,  and  kept  at  a  uniform  temperature  of 
40°  C.  for  two  or  three  hours.  If  there  is  little  normal  HC1  present, 
a  few  drops  more  juice  should  be  added.  If  no  digestion  occurs  after 
some  hours,  pepsin  is  absent  and  the  fibrin  will  decompose.  Quan- 
titative or  comparative  tests  may  be  made  by  using  definite  amounts 


INDIGESTION  AND  DYSPEPSIA  577 

of  fibrin  and  gastric  juice,  and  noting  the  time  required  for  complete 
digestion. 

Test  for  Rennet  Ferment. —  The  presence  of  the  rennet  ferment 
or  rennin  is  easily  demonstrated  by  adding  a  few  cubic  centimeters  of 
the  filtered  gastric  juice  to  a  half-teacupful  of  fresh  milk,  and  keeping 
the  mixture  for  a  short  time  at  40°  C.  A  loose  coagulum  forms  with 
a  limpid  yellowish  whey  if  rennin  be  present. 

Clinical  Value  of  the  Chemical  Tests  of  Gastric  Contents. —  It  is 
important  not  to  place  too  much  reliance  upon  a  single  gastric  juice 
analysis,  for  the  following  reasons:  (a)  The  test  meals  are  usually 
not  sufficiently  appetizing  to  stimulate  copious  secretion.  The  gas- 
tric secretion  is  stimulated  into  activity  in  part  through  the  senses  of 
smell  and  taste,  in  part  through  the  mechanism  of  deglutition,  and  in 
part  by  the  mechanical  and  chemical  influences  exerted  by  the  food 
when  in  the  stomach.  A  roll  and  glass  of  water  or  cup  of  weak  tea 
may  entirely  fail  to  promote  secretion  through  these  means.  (&) 
The  mechanism  of  secretion  is  further  complicated  by  the  extensive 
nerve  influences  which  control  it,  and  which  easily  may .  inhibit  it. 
Thus  the  nervous  dread  of  the  passage  of  the  stomach  tube,  or 
the  disagreeable  choking  sensation  induced  by  its  first  passage, 
may  modify,  if  they  do  not  inhibit,  gastric  secretion.  I  have  a  large 
number  of  records  of  analyses  made  by  Dr.  William  Armstrong  at  my 
Clinic  upon  patients  upon  successive  days,  which  show,  for  example, 
anacidity  one  day,  hyperacidity  the  next,  hypoacidity  the  next,  etc. 
Such  patients  are  often  neurasthenic,  but  I  have  known  patients  in 
hospital  with  minor  ailments  who  kept  on  eating  full  house  diet  and 
grew  stout  upon  it,  yet  who  were  reported  from  the  clinical  laboratory 
as  having  entire  absence  of  free  hydrochloric  acid  and  a  mere  trace  of 
combined  acid.  For  these  reasons  little  satisfactory  conclusion  is  to 
be  drawn  in  a  given  case  unless  the  average  be  taken  of  at  least  three 
analyses  made  under  varying  conditions  and  with  different  kinds  of 
test  meals  for  comparison.  For  example,  the  Ewald  test  breakfast 
may  fail  to  promote  an  acid  secretion,  which  is  obtainable  promptly 
with  a  Leube  test  meal. 

The  presence  of  hyperacidity  is  somewhat  more  reliable  than  that 
of  anacidity,  and  in  general  a  better  knowledge  of  the  condition  of 
digestion  and  of  the  stomach  itself  is  obtained  by  tests  of  motility, 
inflation,  and  percussion,  the  microscopic  examination  of  food  con- 
tents, the  search  for  mucus,  fungi,  bacteria,  etc.,  than  by  purely  chem- 
ical analyses. 

The  quantity  of  a  test  meal  recovered  by  siphonage  depends  upon 
the  motility  of  the  stomach,  as  well  as  the  activity  of  secretion,  and 


578  DIET  IN  DISEASES  OF  THE  STOMACH 

percentage  acidity  is  therefore  a  very  imperfect  index  of  the  activity 
of  secretion. 

Tests  for  Motor  Power  of  the  Stomach. —  The  motor  power  of  the 
stomach  is  demonstrated  in  various  ways. 

Leube's  Method. —  Leube's  method  is  to  examine  the  stomach  with  a 
tube  after  the  ingestion  of  a  Leube's  test  dinner  (p.  572),  or  Ewald's 
test  breakfast  (p.  572).  If  the  stomach  is  empty  three  hours  after  the 
former  and  one  and  a  half  after  the  latter,  hypermotility  is  present 
—  i.  e.,  the  food  is  being  too  rapidly  hurried  into  the  duodenum.  If 
undigested  food  remains  six  or  seven  hours  after  eating  the  Leube  test 
dinner,  the  motility  is  impaired,  or  gastric  atony  is  present,  and  the 
diet  should  be  regulated  accordingly.  (See  Chronic  Gastric  Catarrh, 
p.  590,  and  Dilatation,  p.  597.) 

Ewald  and  Siever's  Method. —  Another  method,  that  of  Ewald  and 
Siever,  is  simple,  but  not  very  reliable.  Fifteen  grains  of  salol  are 
given  in  a  wafer  immediately  after  a  meal,  and  the  urine  is  tested  for 
salicyluric  acid,  which  is  derived  from  salicylic  acid  formed  in  the 
alkaline  intestine  as  one  of  the  products  of  dissociation  of  salol.  Salol 
escapes  being  acted  upon  by  the  gastric  juice,  and  the  salicyluric  acid 
appears  in  the  urine  half  an  hour  or  an  hour  after  it  is  swallowed 
if  hypermotility  be  present  —  otherwise,  not  for  several  hours.  The 
salicyluric  acid  is  readily  detected  by  the  violet  color  which  appears 
in  the  urine  on  adding  a  drop  or  two  of  ferric-chloride  solution.  The 
chief  difficulty  in  the  performance  of  the  test  is  in  getting  urine  when 
wanted  without  catheterization.  Frequent  catheterization  merely  for 
the  purposes  of  such  a  test  is  to  be  condemned,  and  patients  usually 
cannot  micturate  every  fifteen  minutes.  Brunner  and  Huber  prefer 
to  make  the  test  dependent  upon  the  disappearance  of  all  trace  of 
salicyluric  acid  after  ingestion  of  one  gram  of  salol.  Normally  it  may 
be  detected  for  only  twenty-four  hours,  but  if  the  motor  power  of 
the  stomach  is  impaired  it  may  be  obtained  as  late  as  forty-eight  hours 
after  ingestion. 

Bourget  found  that  the  reaction  time  is  delayed  an  hour  or  more 
by  giving  a  dose  of  HC1  with  a  meat  meal,  whereas  it  is  accelerated 
by  a  less  acid  meal  of  which  fruits  and  vegetables  form  a  part. 

Stewart,  in  referring  to  this  experiment,  points  out  that  hyper- 
acidity of  the  gastric  juice,  by  neutralizing  the  duodenal  juices,  might 
retard  the  salol  reaction  without  the  existence  of  motor  insufficiency. 

Klcmpcrcrs  Method. —  Klemperer  has  the  patient  swallow  100 
grams  of  olive  oil  into  an  empty  stomach,  or  the  oil  may  be  poured  in 
through  a  stomach  tube.  It  is  left  for  two  hours,  and  then  the  stom- 
ach is  washed  OUT.  The  oil  is  abstracted  from  the  washing  with  ether, 


INDIGESTION  AND  DYSPEPSIA  579 

and  the  ether  is  separated.  The  oil  is  then  measured.  Between  70 
and  80  grams  of  oil  should  pass  on  into  the  intestine  inside  of  two 
hours,  but  if  it  has  not  done  so  there  is  lack  of  motility. 

Sahli  has  devised  a  test  meal  of  a  soup  of  butter,  flour,  salt,  and 
water  to  test  the  mobility  and  other  functions  of  the  stomach,  but 
its  preparation  and  use  is  too  elaborate  for  ordinary  clinical  purposes. 

Test  for  Absorptive  Power  of  the  Stomach. —  This  test,  as  devised 
by  Penzoldt  and  Faber,  is  very  simple.  Into  an  empty  stomach  are 
taken  three  grains  of  potassium  iodide  in  a  clean  gelatin  capsule, 
with  a  wineglassful  of  water. 

The  saliva  is  collected  at  two-  or  three-minute  intervals  in  separate 
saucers,  and  with  normal  absorption  from  a  healthy  stomach  iodine 
may  be  detected  in  the  secretion  in  from  six  and  a  half  to  fifteen  min- 
utes, but  in  gastric  catarrh  it  may  not  appear  for  several  hours.  The 
test  is  made  by  dipping  a  filter  paper,  previously  soaked  in  starch 
paste,  into  the  saliva,  and  adding  fuming  nitric  acid.  A  blue  color 
appears  if  iodine  is  present.  This  test  is  not  very  reliable,  for  if  the 
stomach  is  full  of  food  the  reaction  is  much  retarded,  as  it  also  is  by 
fever  and  in  most  diseases  of  the  stomach,  notably  ulcer,  carcinoma, 
and  dilatation. 

Bacteria  in  the  Stomach. —  The  bacterial  flora  of  the  stomach  is 
highly  varied,  and  its  study  quite  as  important  as  mere  chemical  anal- 
yses of  gastric  juice.  Abelous  has  described  16  species  of  microorgan- 
isms from  the  stomach  contents  in  health,  including  the  Bacillus 
putrificus  and  Bacillus  acidi  lactici  and  various  yeasts  and  molds,  sev- 
eral of  which  cause  active  fermentation  of  sugars. 

Dietetic  Treatment  of  Dyspepsia 

The  foregoing  details  of  the  clinical  examination  of  the  digestive 
power  of  the  stomach  have  been  given  in  this  connection  as  a  con- 
venient place  to  summarize  them.  It  is  not  intended  to  imply  that 
every  case  of  simple  dyspepsia  should  be  subjected  to  so  complex 
an  examination,  but,  on  the  other  hand,  there  are  many  persons 
afflicted  with  chronic  dyspepsia  who  waste  much  time,  energy,  and 
expense  in  taking  medicines  and  diet  "cures"  which  are  entirely 
unadapted  to  their  particular  trouble  because  it  has  never  been  inves- 
tigated thoroughly.  The  stomach  is  useful  more  as  a  receptacle  for 
food  than  for  its  necessary  digestion  or  absorption,  for  in  cases  of  its 
total  extirpation  or  total  abolition  of  function  digestion  and  nutrition 
may  be  maintained  fully  through  the  intestine.  Hence  it  follows  that 
in  all  gastric  derangements  it  is  desirable  to  impose  as  slight  a  burden 
upon  the  organ  as  possible.  To  this  end  food  should  be  masticated 


580  DIET  IN  DISEASES  OF  THE  STOMACH 

thoroughly,  or  given  only  in  a  state  of  fine  subdivision.  The  food 
should  also  be  as  concentrated  as  possible,  and  if  necessary  given  in 
small  quantities  at  frequent  intervals. 

The  dietetic  treatment  of  dyspepsia  is  so  complex  that  it  is  easier 
for  some  persons  to  be  put  upon  a  very  restricted  diet  for  two  or  three 
weeks  than  to  have  to  select  for  themselves  appropriate  articles  at 
each  meal.  It  includes  the  study  of  all  classes  of  foods,  and  for  con- 
venience they  may  be  grouped  into  — 

A.  Foods  forbidden  in  all  cases.  B.  Foods  occasionally  allowable. 
C.  Foods  which  are  desirable. 

A.  Foods  Forbidden  in  All  Cases. — 

1.  Eich  soups,  gravies,  and  sauces. 

2.  Strong  condiments,  pickles,  vinegar. 

3.  Fresh  soft  bread  of  any  kind  (which  makes  a  tenacious  bolus), 
hot   breads,   all   kinds   of   pastry,   cakes,   griddle   cakes,   doughnuts, 
muffins. 

4.  Sweets,  tarts,  jams,  confectionery  and  candies  of  every  kind. 
Sugar  in  all  forms,  especially  in  coffee  and  tea  with  milk. 

5.  Baw  vegetables,  such  as  celery,  radishes,  cucumbers. 

6.  Heavy  vegetables  —  sweet  potatoes,  corn,  peas,  beans,  beets,  egg- 
plant, cabbage,  cauliflower,  Brussels  sprouts,  turnips,  carrots,  parsnips 
(nearly  all  the  roots  and  tubers).     Peppers,  romaine.  cucumbers,  rad- 
ishes, cranberries. 

7.  Fat  in  quantity,  all  fried  or  greasy  food. 

8.  Clams,  mussels,  lobsters,  crabs,  shrimps,  salmon,  herring,  bluefish. 

9.  Dried,  smoked,  cured,  potted,  or  "  devilled  "  meats  or  fish. 

10.  Corned  beef,  duck,  goose,  wild  fowl,  rabbit.     Veal,  except  as 
broth.     Venison,  pork. 

11.  Twice-cooked  meats,  hash  (unless  freshly  made,  without  pota- 
toes), stews,  ragouts. 

12.  Cheese  of  all  kinds. 

13.  Very  acid  or  very  sweet  fruits,  nuts,  dried  fruits  in  general. 
All  skins  and  seeds  of  fruits. 

14.  Tea,  beer,  and  sour  wines. 

The  excessive  use  of  tobacco  in  any  form  should  be  forbidden. 

B.  Foods  Occasionally  Allowable. —  There  are  foods  which  may  be 
allowed  to  some  patients  but  not  to  others,  and  many  of  them  consti- 
tute exceptions  to  general  rules.  Such  are: 

Vegetables. —  Mealy,  well-baked  potatoes,  not  too  young  or  new, 
raw  tomatoes,  spinach,  thoroughly  boiled  onions,  very  young  tender 
fresh  peas,  very  young  Lima  beans,  string  beans,  asparagus,  stewed 
celery,  celery  plant  (sea-kale). 


INDIGESTION  AND  DYSPEPSIA  581 

Starchy  Foods. —  Where  it  is  desirable  to  give  starchy  food  in 
some  form,  macaroni,  spaghetti,  or  rice,  may  be  allowed,  or  one  of 
the  prepared  foods,  such  as  Carnrick's  or  Mellin's.  All  starchy  foods 
should  be  cooked  most  thoroughly,  for  salivary  digestion  is  often 
feeble  in  connection  with  gastric  disorders. 

Fats. —  Bacon,  very  fat,  sliced  thin  and  well  broiled;  cream,  good 
fresh  butter,  olive  oil. 

Eggs. —  Many  patients  find  that  eggs  disagree  with  them  con- 
stantly. There  are  a  few  who  can  take  them  with  impunity  if  rightly 
cooked  —  that  is  cooked  very  slowly  and  soft.  They  sometimes  agree 
better  when  not  given  with  other  food,  but  as  eggnog. 

Fruits. —  As  a  rule,  sweet  fruits  disagree,  though  they  may  be  eaten 
by  some  patients. 

C.  Desirable  Foods  to  Be  Recommended  in  Ordinary  Cases. — 

Cereals. —  Wheaten  bread,  porous  or  aerated,  stale  or  toasted;  dry, 
unsweetened  rusk  or  zwieback;  soda  crackers.  (The  bread  from 
some  bakers  is  easier  of  digestion  than  that  from  others  because  bet- 
ter aerated.)  Macaroni,  puffed  or  boiled  rice,  hominy  without  sugar. 

Fats. —  In  moderation  only;  butter  to  be  very  thinly  spread  and 
well  rubbed  in.  Sometimes  a  thin  slice  of  bacon. 

Vegetables. —  Chiefly  as  purees,  thoroughly  cooked,  made  of  toma- 
toes, asparagus,  or  sometimes  potatoes  or  fresh  peas.  (Fresh  green 
vegetables  as  in  preceding  list.)  Lettuce. 

Fish. —  Oysters,  fresh-boiled  or  broiled  fish  without  rich  sauces. 
They  may  be  eaten  with  a  little  fresh  butter  and  salt.  (Some  per- 
sons cannot  eat  fish  at  all.) 

Eggs. —  In  any  form  if  they  are  found  to  agree  (except  hard- 
boiled  or  fried). 

Sweetbreads,  Meats. —  Broiled  steak  or  chop,  tender  roast  beef  or 
mutton,  chicken  (roasted  or  boiled),  boiled  capon,  roast  partridge, 
quail,  grouse,  woodcock,  plover,  squab,  guinea-chicken.  All  meats 
should  be  short-fibered  and  tender.  They  need  not  be  very  rare. 
Grilling  is  the  best  method  of  cooking  them. 

Fruit. —  Baked  or  stewed  apples  or  prunes.  Occasionally  a  little 
fresh  fruit  in  season,  better  eaten  between  meals  to  prevent  consti- 
pation. Oranges,  peaches,  grape  fruit. 

In  serious  cases  the  diet  should  be  restricted  further,  and  a  bread- 
and-milk  regimen  may  have  to  be  enforced  until  improvement  occurs. 

Beverages. —  Tea  is  generally  injurious,  especially  if  drunk  with 
meals,  but  weak  tea  taken  clear  in  very  hot  water  with  lemon  is  some- 
times beneficial  by  enabling  patients  to  imbibe  the  fluid  which  they 
need.  Strong  tea  is  astringent;  it  precipitates  pepsin  and  provokes 


582  DIET  IN  DISEASES  OF  THE  STOMACH 

constipation.  Coffee,  on  the  contrary,  favors  peristalsis,  and  is  mildly 
stimulating  to  the  nervous  system.  Drunk  with  milk  and  sugar  it 
often  excites  dyspepsia  and  increases  flatulency.  Coffee  does  not 
itself  ferment,  but  the  milk  and  sugar  drunk  with  it  does.  Taken 
black  after  dinner  it  is  an  adjunct  to  digestion.  If  it  produces  in- 
somnia or  "  nervousness  "  it  should,  of  course,  be  discontinued. 

Cocoa  (not  chocolate,  which  is  too  sweet)  may  be  allowed.  An 
infusion  of  cocoa  nibs  often  agrees. 

Milk  or  cream  with  Vichy,  Seltzer  or  soda  may  be  drunk  as  a 
beverage  in  non-flatulent  cases.  Koumiss  and  buttermilk  are  al- 
lowed. 

As  a  general  rule,  malt  liquors  and  beers  of  all  kinds  are  forbid- 
den, although  Fagge  recommends  the  use  of  light,  still,  bitter  ale  or 
of  porter  in  some  cases ;  but  he  says,  "  Whatever  causes  flushing  of 
the  face  after  meals  is  bad."  Alcoholic  dyspepsia  is  only  cured  by 
entire  cessation  of  drinking.  This  the  patients  are  unwilling  or 
unable  to  accede  to  unless  very  strongly  influenced  or  frightened  as 
to  the  probable  outcome  of  continued  indiscretion.  In  simple  atonic 
dyspepsia  in  non-alcoholic  patients,  the  use  of  pure  wine,  or  weak 
brandy,  or  whisky  and  water  drunk  at  meals  may  prove  service- 
able. Sometimes  a  little  dry  wine,  claret,  or  hock  may  be  allowed 
twice  a  day  with  meals. 

Tobacco,  smoked  in  great  moderation,  in  the  form  of  mild  cigars 
or  in  pipes  (not  cigarettes),  sometimes  promotes  digestion  by  slightly 
stimulating  the  nervous  system  and  increasing  peristalsis.  (See  To- 
bacco and  Food,  p.  404.) 

Special  Systems  of  Treatment. —  The  following  systems  of  treat- 
ing dyspepsia  are  condensed  from  the  writings  of  several  of  the  best- 
known  dietists: 

Dujardin-Beaumetz  divides  dyspepsia  into  three  classes,  and  regu- 
lates the  diet  accordingly,  as  follows: 

I.  Dyspepsia  with  abundant  gastric  juice.     Diet,  fresh  vegetables 
and  fruits,  farinaceous  food,  milk,  no  meat  or  wine. 

II.  Dyspepsia   with   deficient   gastric   juice.     Diet,   meat,   broths, 
milk,  peptonized  food.     No  vegetables  or  saccharine  food. 

III.  Dyspepsia    with    sympathetic    affections,    especially    vertigo. 
Diet,  purely  vegetable  food. 

His  diet  of  vegetable  food  is  very  liberal,  and  includes  cereals  as 
well  as  fruits.  It  contains  such  articles  as  dry  bread  crust,  toast; 
farinaceous  purees  made  of  one  of  the  following  materials:  Maize, 
flour,  chestnut  meal,  oatmeal,  pearl  barley,  potatoes,  lentils,  reva- 
lenta,  macaroni  (plain  or  buttered),  vermicelli;  purees  of  fresh  vege- 


INDIGESTION  A'ND  DYSPEPSIA  583 

tables,  such  as  green  peas,  carrots,  turnips ;  the  vegetables  of  Julienne 
soup;  salads,  spinach,  sorrel,  French  beans,  fruits  (except  grapes), 
cooked  as  compote,  lightly  cooked  eggs. 

Germain  See's  treatment  of  dyspepsia  is  exactly  the  reverse  of  that 
of  Dujardin-Beaumetz.  He  divides  dyspeptics  into  two  classes : 

I.  Those  who  have  hyperacidity  of  the  gastric  juice,  for  whom  he 
prescribes  a  nitrogenous  diet  with  sodium  bicarbonate  after  meals. 

II.  Those  having  diminished  acidity,  for  whom  he  prescribes  a 
purely  vegetable  regimen,  with  dilute  hydrochloric  acid  taken  shortly 
after  meals. 

He  directs  in  all  cases  washing  out  the  stomach  and  stimulating 
the  gastric  mucous  membrane,  for  which  he  orders  the  alkaline 
sodium  bicarbonate  in  a  tumblerful  of  Vichy  an  hour  and  a  half  be- 
fore eating. 

Leube  graduates  dyspeptics  into  four  groups  according  to  the 
severity  of  their  symptoms.  The  diet  which  he  recommends  is  as 
follows,  commencing  with  the  gravest  cases : 

I.  Broth  or  clear  soup,  Leube's  meat  extract,  milk,  eggs  (raw  or 
lightly  cooked),  carbonic-acid  water,  Apollinaris,  or  Seltzer. 

II.  Boiled  calves'  brains,  sweetbread,  breast  of  chicken  or  squab, 
bread  and  milk,  custard,  unsweetened  tapioca  pudding. 

III.  The  same  as  the  two  preceding,  with  the  addition  of  raw 
ham  [sic]  and  rump  steak.     The  latter  is  strongly  beaten,  scraped, 
and  roasted  quickly  before  a  hot  fire  with  a  little  fresh  butter. 

IV.  This  diet,  intended  for  the  mildest  cases  or  for  convalescence, 
includes  milk,  rice,  spinach,  roast  chicken,  partridge,  venison,  rare 
beef,  veal,  macaroni,  fresh  green  vegetables,  salads,  fruit  compotes, 
stewed  apples,  and  light  wines.     He  sometimes  allows  fish,  such  as 
bass. 

General  Rules  for  Dyspeptics. —  The  following  general  rules  are  ap- 
plicable to  all  cases  of  dyspepsia  and  indigestion: 

1.  Eat  slowly,  masticate  thoroughly.  2.  Avoid  too  much  variety 
at  any  one  meal.  Take  meats  and  vegetables  at  separate  meals.  3. 
Drink  fluid  an  hour  before  and  two  or  three  hours  after  meals,  rather 
than  with  food.  4.  Eat  at  regular  hours.  5.  If  greatly  fatigued, 
lie  down  and  rest  quietly  before  and  after  luncheon  and  dinner  or 
supper.  6.  Avoid  as  far  as  possible  taking  business  worries  or  pro- 
fessional cares  to  the  table.  7.  Take  systematic  exercise  in  the  open 
air.  Bicycle  and  horseback  riding  are  the  best  forms  if  patients  are 
strong  enough.  8.  On  rising,  cold  sponging  and  vigorous  friction  of 
the  body  is  advisable.  9.  The  bowels  should  be  kept  open  by  laxa- 
tive foods  and  fluids  rather  than  bv  medicines. 


584  DIET  IN  DISEASES  OF  THE  STOMACH 

Rules  for  Special  Varieties  of  Dyspepsia 

Dyspepsia  with  Excessive  Flatulency. —  This  often  occurs  in  ner- 
vous women  and  neurasthenic  men,  and  is  especially  annoying  at 
night. 

Avoid  particularly  all  sweets  and  amylaceous  food.  Take  no  fluid 
with  meals.  Drink  hot  water,  half  a  pint  before  meals,  and  again 
two  hours  after.  Do  not  eat  vegetables  and  meat  at  the  same  meal. 
Try  cream  instead  of  milk  in  coffee,  and  saccharin  instead  of  sugar. 
Avoid  tea  and  alcohol  (especially  malt  liquors),  and  effervescing 
waters,  with  meals. 

Dyspepsia  with  Hyperacidity. —  The  diet  should  consist  largely  of 
rare  finely  minced  or  scraped  beef  (three  and  a  quarter  ounces  is 
ample),  with  two  slices  of  stale  bread  or  toast,  or  a  few  crackers  with 
a  little  butter  (an  ounce).  Later  the  patient  may  partake  of  the 
lighter  fresh  vegetables  and  subacid  fruits.  Milk  may  be  useful,  with 
10  grains  of  sodium  bicarbonate  to  the  tumblerful.  Vegetables 
should  be  thoroughly  cooked  and  mashed  or  made  into  purees.  Fruit 
may  be  stewed  or,  in  the  case  of  apples,  baked.  Alkaline  Vichy  may 
be  drunk  after  meals. 

A  few  weeks'  course  of  such  a  diet  faithfully  adhered  to  often  re- 
sults in  cure. 

Dyspepsia  with  Excessive  Nervousness;  Irritative  Dyspepsia. — 
Avoid  tea,  coffee,  much  alcohol,  tobacco,  stimulating  food  of  all  sorts, 
condiments  and  pickles,  and  do  not  overeat.  Eat  slowly.  Avoid  eat- 
ing when  fatigued  or  worried.  Take  one  or  two  extra  meals  a  day, 
if  necessary,  especially  a  light  one  before  retiring,  to  promote  sleep. 
(See  Insomnia.) 

In  the  main,  vegetable  food  will  be  tolerated  better  than  proteids, 
unless  flatulency  is  annoying. 

Atonic  Dyspepsia ;  Dyspepsia  with  Deficient  Gastric  Juice. —  Take 
three  meals  per  diem,  and  freshly  cooked  meat  should  be  included 
in  two  of  them.  Beef,  mutton,  and  poultry  are  recommended.  Meat 
broths  and  soup,  stale  bread,  toast,  or  crackers.  All  meats  should 
be  tender  and  simply  cooked. 

In  purely  atonic  dyspepsia,  with  loss  of  tone  in  the  muscular  wall 
of  the  stomach  and  sluggish  secretion,  a  diet  which  is  too  bland  and 
tasteless  fails  to  stimulate  the  stomach  sufficiently,  and  it  is  better  to 
offer  a  reasonable  variety  and  a  moderate  use  of  condiments. 

Dyspepsia  in  the  Gouty. —  Avoid  particularly  sugar  in  every  form, 
much  meat,  pastry,  malt  liquors,  sweet  wines,  and  champagne.  (See 
Gout  for  details.) 


INDIGESTION  AND  DYSPEPSIA  585 

Dyspepsia  with  Bulimia. —  A  certain  class  of  dyspeptics  are  always 
abnormally  hungry,  for  hunger  is  a  general  sense,  due  to  the  needs  of 
the  tissues  rather  than  to  the  purely  local  condition  of  the  stomach. 
Suffering  from  indigestion,  they  fail  to  assimilate  food  properly, 
become  hungry  again  soon  after  meals,  and  do  not  obtain  the  full 
nutritive  value  of  what  they  do  eat.  They  therefore  overeat  or  eat 
between  meals,  and  do  not  give  the  stomach  sufficient  time  for  rest. 
They  should  be  taught  to  restrain  the  appetite  and  to  stop  eating  short 
of  satiety  to  prevent  overloading  the  stomach,  and  a  sufficiently  long 
period  should  intervene  between  meals  for  the  thorough  digestion  of 
the  food.  These  patients  often  have  hyperacidity.  (See  Bulimia, 
p.  370.) 

Dyspepsia  with  Anaemia. —  Anaemic  patients  require  abundant 
nitrogenous  food,  and  well-seasoned,  stimulating  meat  broths,  eggs, 
and  custards  are  recommended.  Such  patients  may  take  an  extra 
luncheon  or  two  between  the  regular  meals  and  before  retiring.  (See 
Anaemia,  p.  539.) 

Dyspepsia  in  Infants  and  Children 

Children  vomit  much  more  easily  than  adults  when  they  have 
taken  improper  food,  and  often  suffer  less  in  consequence,  although, 
if  such  food  is  retained,  they  may  have  a  gastric  fever  with  a  greater 
rise  of  temperature  and,  perhaps,  more  alarming  symptoms  than 
occur  later  in  life. 

Infants  may  suffer  from  three  forms  of  milk  indigestion,  i.  e., 
indigestion  of  fats,  sugar,  or  proteids,  either  singly  or  combined. 
By  far  the  commonest  type  is  proteid  indigestion,  when  the  infant 
is  fed  upon  cow's  milk.  The  treatment  is  dietetic,  by  first  withhold- 
ing milk  altogether  for  a  short  time,  substituting  egg  albumen,  or 
farinaceous  gruels,  etc.,  and  then  using  modified  milk  (p.  103),  ac- 
cording to  the  type  of  indigestion.  The  latter  is  determined  by  exam- 
ination of  the  vomitus  and  stools.  Whey  is  often  a  useful  tem- 
porary food  when  proteid  digestion  is  at  fault. 

When  vomiting  occurs  in  infants  the  stomach  should  be  rested 
by  omitting  the  next  feeding,  and  for  the  second  feeding  the  milk 
should  be  diluted  and  reduced  in  quantity.  If  vomiting  persists,  a 
little  bicarbonate  of  soda  or  one  or  two  tablespoonfuls  of  lime  water 
should  be  added  to  each  feeding.  Other  substances,  such  as  gelatin 
or  one  of  the  prepared  infant  foods,  may  be  used  to  dilute  the  milk 
and  prevent  the  formation  of  large  curds  in  the  stomach.  In  ob- 
stinate cases  it  may  be  well  to  change  the  diet  completely  and  give  up 
milk  for  a  few  days.  In  place  of  it  a  mixture  may  be  used  consisting 
40 


586  DIET  IN  DISEASES  OF  THE  STOMACH 

of  one  part  of  cream  and  two  parts  each  of  whey  and  boiled  (not  boil- 
ing) water. 

An  overfed  infant  vomits  soon  after  nursing  or  taking  the  bottle, 
and  the  stools  contain  milk  curds.  When  an  infant  receives  too  little 
food,  "the  bottle  is  emptied  quickly  and  ravenously;  the  child  cries 
when  it  is  taken  away,  sucks  violently  at  its  fingers,  and  cries  before 
the  next  feeding  is  due"  (Holt). 

Older  children  should  not  be  allowed  to  eat  between  meals,  and 
should  be  forbidden  the  premature  use  of  coffee,  tea,  spices,  coarse 
vegetables  (cabbage,  turnips,  etc.),  and  unlimited  ice  water,  fruits, 
and  sweets.  (See  the  sections  on  Diet  for  Infants,  and  Diet  for  Chil- 
dren. 

ACUTE  GASTRITIS 

Causation. —  Acute  gastric  catarrh  is  commonly  due  to  dietetic 
errors,  although  it  is  also  excited  in  other  ways.  The  dietetic  causes 
are: 

1.  Food  taken  in  too  large  quantity. 

2.  Food  too  hastily  swallowed  or  "  bolted." 

3.  Food  in  itself  irritant  or  too  highly  seasoned  with  sauces,  con- 
diments, fats,  etc. 

4.  Food  which  has  undergone  decomposition,  such  as  "  high  "  game 
or  fish,  overripe  cheese,  sour  milk,  or  improperly  canned  vegetables. 

5.  Alcohol  habitually  consumed  in  excess  and  in  concentrated  form, 
or  a  combination  of  drinking  beer  and  wine  or  liquor,  or  drinking 
beer  in  excess  with  improper  food. 

Many  persons  appear  to  have  special  weakness  or  irritability  of  the 
stomach,  so  that  attacks  of  gastric  catarrh  are  excited  in  them  by  con- 
ditions which  would  prove  insufficient  in  others. 

Excessive  consumption  of  food  beyond  the  wants  of  the  system 
and  out  of  proportion  to  the  gastric  juice  is  often  an  exciting  cause 
of  gastric  catarrh,  especially  in  children.  This  food  need  not  in 
itself  be  indigestible.  Such  cases  may  result,  for  example,  from 
bolting  large  quantities  of  meat  hash  or  of  ice  cream.  Contributing 
factors  exist  in  anaemia,  nervous  exhaustion,  convalescence  from  pro- 
tracted illness,  and  in  fevers,  in  all  of  which  conditions  the  gastric 
juice,  and  especially  its  hydrochloric  acid,  is  liable  to  be  diminished 
in  amount  or  temporarily  absent.  In  these  cases  digestion  is  re- 
tarded far  beyond  the  ordinary  limits,  and  the  retained  food  decom- 
poses by  abnormal  fermentation,  thus  becoming  both  a  mechanical 
and  a  chemical  irritant  to  the  mucous  membrane. 


ACUTE  GASTRITIS  587 

Symptoms. —  The  chief  symptoms  dependent  upon  the  local  inflam- 
mation of  the  stomach  are  severe  vomiting,  nausea,  local  pain  and 
tenderness,  weakness,  and  fever. 

Dietetic  Treatment. —  Acute  inflammation  of  any  structure  is  best 
treated  by  rest,  and  the  stomach  forms  no  exception.  Hence  total 
abstinence  from  food  and  reduction  in  the  quantity  of  fluid  imbibed 
is  often  curative  after  an  interval  of  twenty-four  or  thirty-six  hours. 
The  irritation  is  maintained  by  ill-advised  attempts  to  give  food  at 
frequent  intervals  with  the  object  of  supporting  the  strength.  The 
attacks,  from  the  very  nature  of  their  causation,  often  arise  in  robust 
persons  who  may  well  afford  to  forego  nourishment  for  a  few  hours 
or  until  the  nausea  and  pain  cease.  To  others  who  have  been  en- 
feebled by  continued  illness  or  in  whom  the  acute  attack  produces 
alarming  prostration,  enemata  and  stimulants  and  predigested  albu- 
minoid food  should  be  given. 

The  vomiting  and  nausea  are  allayed  by  cracked  ice,  small  quan- 
tities of  iced  champagne,  carbonic-acid  water,  plain  soda  wa^er,  cold 
lime  water  sipped  in  doses  of  a  tablespoonful  at  a  time  and  at  inter- 
vals of  fifteen  minutes.  Strong  black  coffee  is  also  serviceable. 
These  symptoms  may  be  relieved  also  by  hot  poultices  and  turpen- 
tine stupes,  or  spongilopiline  soaked  in  hot  water  and  sprinkled  with 
a  few  drops  of  laudanum  placed  over  the  episgastrium. 

The  thirst  should  not  be  met  by  large  draughts  of  water,  which 
only  distend  the  stomach  and  excite  vomiting.  It  may  be  relieved 
by  sucking  a  piece  of  sliced  lemon  or  by  placing  a  few  drops  of 
mineral  acid,  such  as  dilute  phosphoric  or  dilute  hydrochloric  acid, 
in  a  small  tumbler  of  cold  water  and  sipping  it  from  time  to  time. 
Thirst  may  be  lessened  in  some  cases  by  holding  water  in  the  mouth 
for  a  few  moments  without  swallowing  it,  for  a  certain  amount  of 
fluid  is  absorbed  directly  through  the  buccal  mucous  membrane.  If 
large  quantities  of  fluid  have  been  vomited,  a  simple  enema  of  salt 
and  water  (a  half  drachm  to  the  pint)  may  be  injected  into  the  rec- 
tum, where  it  is  soon  absorbed. 

When  nourishment  is  first  taken  by  the  mouth,  it  should  be  fluid, 
so  that  it  will  either  undergo  prompt  absorption  or  pass  into  the 
duodenum  for  digestion.  It  should  be  administered  only  in  small 
doses  —  half  an  ounce  or  an  ounce  at  a  time.  Pancreatinized  milk, 
or  cold  milk  diluted  with  an  equal  volume  of  lime  water  or  soda  water 
or  alkaline  Vichy,  milk  whey  flavored  with  beaten  white  of  egg  added, 
beef  extracts,  peptone  solutions,  black  coffee,  expressed  meat  juice, 
and  beef  tea  properly  made,  are  all  recommended.  (See  Keceipts  for 
Invalid  Foods.)  Milk  given  alone  or  undiluted  soon  curdles  in  the 


588  DIET  IN  DISEASES  OF  THE  STOMACH 

stomach,  and  is  promptly  ejected  in  large  tough  coagulse.  Many  per- 
sons either  cannot  digest  milk,  or  more  often  think  they  cannot,  and 
avow  a  violent  distaste  for  it,  declaring  that  it  leaves  a  perpetual  bad 
taste  in  the  mouth  and  causes  headache  and  nausea.  Their  experience 
is  usually  based  upon  the  use  of  undiluted  and  not  predigested  milk, 
and  with  tact  and  perseverance  they  may  be  got  to  retain  and  digest 
milk  in  some  form.  (See  Milk  Predigestion,  p.  90.)  Some  patients 
prefer  warm  milk  diluted  with  water  and  flavored  with  a  little  cin- 
namon, a  trace  of  coffee  or  caramel,  or  they  may  take  barley  or  rice 
water.  If  patients  cannot  drink  milk  they  may  be  allowed  mutton, 
veal,  or  chicken  broths  from  which  the  fat  has  been  removed. 

It  is  best  to  forbid  all  alcoholic  fluids,  unless  the  patient  is  so 
exhausted  that  some  stimulation  becomes  necessary,  in  which  case 
champagne  or  brandy  diluted  with  soda  water  may  be  given  in  small 
quantities,  or  it  may  be  added  to  beef  tea  or  arrowroot  gruel.  It  is 
important  always  to  aid  the  recovery  of  the  digestive  organs  by  abso- 
lute bodily  and  mental  quiet. 

Convalescence. —  In  convalescence  the  diet  should  be  increased  very 
slowly;  otherwise  relapse  may  follow,  and  the  gastric  mucus  accu- 
mulates with  more  butyric-acid  fermentation,  and  the  vomiting  and 
other  symptoms  return. 

At  first  only  one  article  at  a  time  should  be  added  to  the  fluid  food, 
gradually  replacing  it.  Broths  may  be  thickened  by  beaten  or  dropped 
eggs,  crumbled  toast,  or  scraped  beef  or  chicken.  Later  plainly 
cooked  meat,  such  as  broiled  tenderloin  steak,  chicken,  a  tender  chop, 
squab,  or  a  bit  of  broiled  fresh  fish  with  lemon  juice  may  be  allowed 
with  dry  toast  and  rice  pudding,  or  baked  custard. 

It  is  well  to  give  dilute  hydrochloric  acid  (15  to  20  drops)  with 
10  drops  of  tincture  of  nux  vomica  after  each  meal.  When  the  illness 
has  been  very  severe  the  patient  should  be  cautioned  to  be  careful  in 
eating  for  several  weeks  after  the  acute  symptoms  have  subsided  lest 
a  relapse  or  gastric  dilatation  occur.  Alcoholic  subjects  will  prob- 
ably not  heed  this  warning,  but  it  should  be  given  none  the  less. 

Acute  Gastritis  in  Infants  and  Children 

Acute  gastritis  in  infants  is  oftenest  due  to  improper  feeding.  It 
is  also  excited,  or  rather  promoted,  by  teething  and  other  reflex  irrita- 
tions which  interfere  with  the  normal  stomach  functions.  There  is 
an  acute  inflammation  of  the  gastric  mucosa,  accompanied  by  more 
or  less  fever,  'vomiting,  local  pain,  and  anorexia.  This  affection  is 
comparatively  rare  among  nurslings.  When  it  does  occur  in  them, 
the  mother's  milk  should  be  analyzed,  and  any  errors  in  her  own  mode 


CHRONIC  GASTRIC  CATARRH  589 

of  life,  diet,  etc.,  corrected.  If  the  breast  milk  continues  to  disagree, 
a  wet  nurse  may  be  procured,  and,  failing  this,  the  child  should  be 
weaned  if  the  disorder  continues. 

Children  just  weaned  acquire  the  disease  from  overfeeding  and 
from  improperly  prepared  food,  and  the  number  of  meals  should  be 
carefully  regulated  according  to  the  rules  for  infant  feeding. 

Older  children  who  are  allowed  to  come  to  table  develop  the  disease 
from  eating  too  rich  or  stimulating  articles,  such  as  pickles,  sauces, 
spiced  dishes,  sweets,  pastry,  fried  food,  from  drinking  large  quan- 
tities of  very  hot  or  very  cold  fluid,  from  eating  hurriedly  without 
proper  mastication,  or  from  gorging  themselves  with  enormous  quan- 
tities of  foods  of  which  they  are  particularly  fond,  such  as  meat 
hash,  cakes,  etc. 

If  seen  early,  if  vomiting  has  not  already  occurred  and  the  stomach 
is  full,  it  should  be  emptied  by  an  emetic  dose  of  ipecac.  Other- 
wise, if  the  stomach  contents  have  passed  into  the  intestine,  the  irri- 
tating food  should  be  expelled  by  a  laxative,  such  as  calomel  or  gray 
powder.  No  food  should  be  allowed  for  some  hours,  for  it  will  main- 
tain hyperaemia.  Nothing  should  be  swallowed  but  a  few  sips  of 
water  or  a  teaspoonful  of  cool  lime  water  or  a  little  cracked  ice.  After 
ten  or  twelve  hours  of  complete  rest  the  stomach  may  tolerate  one  or 
two  teaspoonfuls  of  pancreatinized  milk  or  milk  diluted  one-half  with 
lime  water  or  Yichy.  If  this  is  not  retained,  it  is  better  to  give  a 
little  meat  juice  or  beef  broth.  The  next  day  mild  farinaceous  food 
may  be  allowed,  such  as  arrowroot,  gruel,  cornstarch,  or  farina. 
Junket  also,  or  milk  toast,  may  be  retained.  It  is  best  to  return  to  a 
solid  diet  very  slowly  and  carefully,  and  such  articles  as  rice  pudding, 
scraped  beef,  the  breast  of  chicken,  or  the  soft  part  of  oysters  may  be 
given  for  a  day  or  two  longer  before  the  regular  diet  is  resumed. 

For  some  time  after  an  attack  it  is  best  to  reduce  the  number  of 
meals  per  diem  —  a  child  who  has  been  taking  five  should  take  four, 
or  one  who  has  had  four  should  take  three. 

CHRONIC  GASTRIC  CATARRH  OR  CHRONIC  GAS- 
TRITIS 

Causation. —  Chronic  gastric  catarrh  may  be  the  outcome  of  such 
errors  in  diet  as  have  been  described  as  causative  of  the  acute  form. 
It  commonly  results,  however,  from  alcoholic  excess.  It  also  accom- 
panies diseases  in  which  the  hepatic,  and  consequently  the  portal  cir- 
culation is  obstructed,  producing  engorgement  of  the  vessels  of  the 
gastric  mucous  membrane.  It  may  complicate  pulmonary  and  car- 


590  DIET  IN  DISEASES  OF  THE  STOMACH 

diac  diseases  which  cause  obstruction  to  the  venous  circulation.  It 
also  is  caused  by  the  severer  forms  of  stomach  diseases. 

Pathological  Physiology. —  Besides  congestion  of  the  blood  ves- 
sels, which  interferes  with  the  maintenance  of  proper  secretion  and 
with  absorption,  the  glands  of  the  stomach  furnish  a  hypersecretion 
of  tenacious,  ropy,  alkaline  mucus,  which  clings  to  the  mucous  coat 
and  prevents  the  food  from  exciting  the  secretion  of  the  gastric 
juice,  and  it  neutralizes  and  prevents  the  latter  from  reaching  the 
food.  The  food  therefore  is  retained  for  hours  in  an  alkaline  me- 
dium, where  it  undergoes  maceration  and  fermentation,  which  is  par- 
ticularly liable  to  develop  large  volumes  of  carbonic-acid  and  marsh 
gas,  which  are  periodically  belched  up  with  such  force  as  to  carry 
out  the  acrid  fluid,  and  even  particles  of  disintegrated  food,  produc- 
ing a  bitter  and  nauseous  taste  in  the  mouth.  The  symptom  of 
heartburn  is  due  to  the  eructation  of  organic  acids.  The  appetite 
is  not  always  lost.  It  may,  in  fact,  be  excessive,  and  it  is  usually  ca- 
pricious. Thirst  is  often  a  prominent  symptom.  Vomiting  takes 
place  at  intervals,  especially  on  rising  in  the  morning,  after  the  gastric 
mucus,  mingled  with  the  saliva  swallowed,  has  accumulated  during 
the  night. 

Dietetic  Treatment. —  If  improvement  is  to  be  hoped  for  in  the 
condition  of  a  patient  with  chronic  gastritis  it  is  absolutely  necessary 
to  secure  the  intelligent  co-operation  of  the  patient  himself  by  strict 
obedience  to  rules  which  should  be  specific  and  distinct.  Many  pa- 
tients will  be  found  to  have  so  little  will  power  that,  with  the  best 
intentions,  when  they  sit  at  the  table  with  others  whose  good  health 
enables  them  to  partake  of  all  the  luxuries  of  the  season  they  are 
unable  to  resist  temptation. 

A  person  suffering  from  chronic  gastritis  often  seems  to  have  only 
a  small  amount  of  nervous  energy  to  expend,  and  if  too  much  is 
diverted  in  other  channels,  little  is  left  for  the  processes  of  digestion, 
and  gland  secretion  is  altered  or  withheld.  It  is  a  matter  of  every- 
day experience  with  such  persons  that  when  free  from  all  concern  and 
anxiety  their  digestion  promptly  improves  and  they  can  often  eat 
quite  indigestible  food,  whereas  much  plainer  food  disagrees  with 
them  while  under  mental  strain.  It  is  important  for  them  that 
meals  should  be  taken  with  regularity  and  that  abundant  time  should 
be  allowed  for  mastication.  Eegular  habits,  outdoor  exercise,  and 
daily  sponge  bathing  in  cold  water,  followed  by  active  friction  of  the 
skin,  are  to  be  recommended  to  patients  whose  strength  permits.  In 
forbidding  certain  classes  of  food,  it  is  often  observed  that  the  patient 
has  discovered  that  some  one  apparently  indigestible  material  may  be 


CHROXIC  GASTRIC  CATARRH  591 

eaten  with  impunity,  and  there  may  be  no  harm  in  allowing  this  to 
be  continued  in  mild  cases.  Sometimes  merely  eliminating  from  the 
diet  such  obviously  indigestible  rich  foods  as  pies,  griddle  cakes, 
pickles,  fried  foods,  or  rich  cheese,  will  produce  marked  improvement, 
but  it  is  usually  necessary  to  enforce  a  very  strict  regimen. 

Milk  Diet. —  Serious  cases,  especially  those  complicating  Bright's 
or  cardiac  disease,  demand  rigorous  restriction  of  the  diet,  and  it 
may  become  necessary  to  give  milk  exclusively  for  two  or  three  weeks. 
From  two  to  two  and  a  half  or  three  quarts  of  fresh  milk  are  required 
for  this  diet  in  the  twenty-four  hours,  the  amount  depending  upon 
the  size  and  weight  of  the  patient.  The  milk  may  be  given  either 
hot  or  cold,  but  hot  milk  is  better.  It  should  be  diluted  with  soda 
water  or  an  alkali,  such  as  sodium  bicarbonate  or  magnesia,  and  salt 
should  be  added.  Grave  cases  with  extensive  atrophy  and  abundant 
mucous  secretion  may  require  pancreatinized  milk  and  beef  prep- 
arations. 

In  some  cases,  especially  those  due  to  chronic  alcoholism,  there 
is  annoying  thirst,  which  is  relieved  by  diluting  the  milk  with  equal 
parts  of  Vichy  or  Apollinaris  water.  The  fluid  has  the  additional 
advantage  of  increasing  the  elimination  of  waste  from  the  system 
through  the  kidneys. 

To  most  patients  who  are  ill  enough  to  require  a  fluid  or  an  exclu- 
sive milk  diet,  it  is  preferable  to  give  food  frequently,  at  the  rate  of 
four  ounces  of  the  above  mixture  once  in  two  hours,  until  the  condi- 
tion of  the  stomach  improves  when  the  dilution  of  the  milk  is  to 
be  reduced,  and  it  is  given  in  larger  quantity  (six  to  eight  ounces), 
while  the  intervals  may -be  prolonged  to  three  hours.  When  much 
gastric  irritation  or  nausea  exists,  the  milk,  if  at  all  rich  in  cream, 
should  be  skimmed,  as  fat  is  not  well  tolerated.  Buttermilk  is  used 
extensively  in  Germany  and  somewhat  in  this  country  for  the  treat- 
ment of  gastric  catarrh.  It  may  be  taken  undiluted.  To  some  per- 
sons the  taste  is  more  agreeable  than  that  of  ordinary  milk.  The 
casein  of  the  buttermilk  is  already  coagulated  and  exists  in  a  con- 
dition of  fine  subdivision,  so  that  it  does  not  form  large  clots  in  the 
stomach.  Patients  usually  tire  sooner  of  buttermilk  than  of  plain 
milk.  Milk,  no  matter  how  given,  is  prone  to  produce  constipation 
and  if  there  is  much  dilatation  of  the  stomach  it  usually  is  contraindi- 
cated. 

Other  Diet. —  Should  it  prove  impossible  for  the  patient  to  digest 
enough  milk  to  support  strength,  his  diet  should  be  supplemented 
with  other  articles  of  food,  such  as  scraped  meat  or  pancreatinized 
meat  juice.  As  a  rule,  the  food  should  be  either  fluid  or  al- 


592  DIET  IN  DISEASES  OF  THE  STOMACH 

most  entirely  solid;  drinking  considerable  fluid  with  solid  food 
dilutes  the  feeble  gastric  juice  too  much  for  proper  digestion.  No 
broth  or  soup  should  be  allowed  with  meals.  Alcohol  should  in  gen- 
eral be  forbidden,  and  tea,  coffee,  or  cocoa  are  to  be  taken  only  in 
moderation,  much  diluted,  and  without  milk  and  sugar.  Occasionally 
light  wine,  such  as  hock  and  Moselle,  may  be  given,  but  effervescing 
wines  are  forbidden.  Fluids  should  not  be  taken  too  cold. 

Oysters  may  be  allowed  either  raw,  broiled,  or  panned.  Butter 
may  be  allowed  very  sparingly,  and  cream  sometimes,  but  in  gen- 
eral fats  and  oils  should  be  avoided  as  well  as  all  fat  meats,  pork, 
sausages,  and  solid  food  cooked  in  grease.  Eich  gravies  and  sauces 
of  every  kind  must  be  forbidden,  and  all  solid  food  should  be  masti- 
cated thoroughly.  Many  patients  live  best  on  a  diet  of  lean  roast 
beef,  rare  steak,  or  white  meat  of  chicken,  eaten  with  stale  white 
bread  or  dry  toast  and  very  little  butter.  This  diet  may  be  taken  for 
some  time  before  serious  objection  is  made  to  it. 

One  occasionally  meets  with  persons  in  whom  the  digestion  of 
salt  and  smoked  meats  seems  to  be  more  easily  accomplished  than 
that  of  fresh  meat.  The  explanation  offered  by  Niemeyer  was  that 
these  preparations  are  less  likely  to  decompose  and  form  abnormal 
fermentation  products  in  the  stomach.  Dried  smoked  beef,  cut  in 
thin  slices  and  eaten  almost  or  quite  raw,  is  palatable  and  easily 
digested.  Some  dyspeptics  can  digest  lean  boiled  ham,  lean  smoked 
bacon,  and  salt  fish,  such  as  shredded  codfish,  thoroughly  cooked, 
better  than  they  can  fresh  meat.  Sweetbreads  and  calves'  brains  are 
digestible.  Tough  meat  and  flesh  of  young  animals  recently  killed, 
such  as  "  bob  "  veal,  should  not  be  eaten. 

Fish  and  soft-cooked  eggs  disagree  with  some  persons,  but  others 
digest  them  without  difficulty. 

Saccharine  and  farinaceous  foods  are  to  be  avoided.  Sooner  or 
later  they  are  certain  to  undergo  lactic  and  butyric-acid  fermenta- 
tion in  the  stomach  with  the  production  of  much  eructated  gas, 
"  sourness "  and  flatus.  Sugar  especially  excites  the  secretion  of 
gastric  mucus.  When  improvement  is  established,  the  patient  may 
gradually  be  allowed  a  little  carefully  prepared  starchy  food,  but 
still  no  sweets  of  any  kind.  A  single  lump  of  sugar  in  a  cup 
of  cafe  au  lait  drunk  at  breakfast  can  produce  an  acute  dyspepsia, 
lasting  all  day.  The  varieties  of  starchy  foods  which  first  may  be 
eaten  are  those  which  have  been  thoroughly  subjected  to  the  heat 
of  baking  or  long  boiling.  Such  are :  Dry  bread  thoroughly  toasted, 
bread  crust,  plain  crackers,  zwieback,  gruels  or  meat  soups  thickened 
with  arrowroot,  thoroughly  cooked  sago,  or  ground  rice,  vermicelli, 


CHRONIC  GASTRIC  CATARRH  593 

and  macaroni  well  boiled.  The  purest  carefully  baked  wheat  bread 
from  hard  white  wheat  flour  agrees  better  than  the  coarser  varieties 
of  brown  bread,  whole-meal  breads,  etc. 

Many  persons  who  take  an  intelligent  but  not  hypochondriacal 
interest  in  their  digestion  find  by  repeated  trial  that  the  bread  of  a 
certain  baker  agrees  with  them,  while  that  of  another  does  not, 
although  its  nutritive  value  for  normal  stomachs  may  be  the  same 
in  both  cases.  This  is  due  to  differences  in  alteration  of  the  bread. 

Potatoes  are  apt  to  produce  flatulency  with  sour  eructations,  and 
when  this  is  the  case  they  should  be  forbidden.  If  roasted  and  very 
mealy  they  sometimes  may  be  allowed.  Among  vegetables  those 
which  are  especially  forbidden  are  cabbage  and  cauliflower,  the  leg- 
umes, and  corn.  A  little  fruit  may  be  allowed  between  meals,  such 
as  cooked  apples,  either  baked  or  stewed,  oranges  or  stewed  prunes, 
if  not  too  sweet. 

Especially  forbidden  are  pastry,  sweets  of  all  sorts,  sweet  puddings 
and  cakes,  griddle  cakes,  hot  breads,  pickles,  fried  foods,  and  strong 
condiments. 

In  all  cases  of  chronic  gastric  catarrh  it  is  important  to  reduce 
the  bulk  of  food  taken  so  as  to  diminish  the  liability  of  its  remain- 
ing in  the  stomach  undigested.  Food  which  is  so  selected  and  pre- 
pared as  to  diminish  the  work  of  the  stomach  should  be  given  only 
at  long  intervals  in  order  that  the  digestion  of  one  meal  may  be 
thoroughly  accomplished  before  the  next  is  eaten.  It  is  well  to 
order  at  least  six-hour  intervals  between  the  meals,  and  they  should 
not  be  eaten  too  soon  after  exercise. 

Convalescence. —  As  the  patient  improves,  the  dietary  may  be  some- 
what enlarged,  and  thoroughly  cooked  fresh  vegetables,  such  as 
spinach,  celery,  asparagus,  onions,  string  beans,  lettuce,  and  fresh 
young  peas,  may  be  added. 

Fresh  ripe  fruit  will  be  found  serviceable  in  curing  constipation, 
which  almost  invariably  follows  as  a  result  of  concentrated  diet.  In 
many  cases  this  trouble  should  be  counteracted  by  the  daily  morning 
use  of  some  aperient,  and  a  half  tumblerful  of  hot  Hunyadi  water, 
or  of  Friedrichshall  bitter  water,  or  a  drachm  or  two  of  Carlsbad  salts 
in  a  tumblerful  of  hot  water,  should  be  taken  each  morning  before 
any  food  is  swallowed.  The  salts  are  further  serviceable  by  diminish- 
ing hyperasmia  of  the  stomach  and  hepatic  engorgement.  Much 
benefit  is  derived  from  drinking  a  glass  of  hot  water  or  a  glass  of  hot 
Vichy  from  half  to  three-quarters  of  an  hour  before  each  meal,  the 
object  being  to  separate  the  layer  of  thick  ropy  mucus  which  over- 
lies the  orifices  of  the  gastric  tubules.  Much  of  the  advantage  to 


594  DIET  IN  DISEASES  OF  THE  STOMACH 

patients  with  chronic  gastric  catarrh  received  from  a  course  of  treat- 
ment at  Carlsbad,  Marienbad,  and  similar  spas  is  due  to  the  action 
of  sulphate  of  soda  and  other  alkalies  in  removing  mucus  from  the 
stomach,  rather  than  to  any  specific  virtue  in  the  salts  contained  in 
the  waters  of  such  springs. 

Hydrochloric  Acid. —  The  value  of  hydrochloric  acid  given  to  aid 
digestion  consists  quite  as  much  in  its  power  to  promote  the  con- 
version of  pepsinogen  into  active  pepsin  as  to  act  directly  upon  the 
food.  The  latter  may  be  accomplished  very  well  by  artificial  digestion 
outside  of  the  body.  If,  therefore,  there  is  complete  atrophy  of  the 
gastric  tubules  in  chronic  gastric  catarrh  of  long  standing,  the  giving 
of  the  acid  fails  to  excite  secretion  from  tubules  permanently  de- 
stroyed, and  Boas  declares  that  the  acid  combines  so  readily  with 
the  salts  and  albuminoids  of  the  food  that  it  is  not  practicable  to 
give  enough  of  it  to  have  any  free  acid  remaining,  and  he  only 
recommends  it  for  those  cases  where  the  function  of  the  gastric 
tubules,  as  shown  by  testing  the  digestive  power  of  a  sample  of  the 
stomach  juice,  is  not  completely  abolished.  He  admits  its  usefulness 
as  an  antifermentative. 

This  view  is  not  generally  held  by  other  clinicians,  however, 
and,  as  a  matter  of  practical  experience,  the  majority  of  these  pa- 
tients improve  by  taking  dilute  hydrochloric  acid  with  any  solid 
animal  food  which  is  allowed  them  which  is  otherwise  found  to  cause 
discomfort.  It  is  best  to  give  the  acid  not  immediately  with  the  food, 
but  half  an  hour  later,  and  twenty  minims  may  be  prescribed  in  one 
dose,  or  two  or  three  doses  of  ten  or  fifteen  minims  may  be  given 
at  intervals  of  half  an  hour.  It  may  be  prescribed  alone  in  half  an 
ounce  of  water,  or  mixed  with  a  little  glycerin  in  a  claret  glassful  of 
water,  and  it  should  be  swallowed  through  a  glass  tube  to  save  the 
teeth  from  injury.  It  is  advantageously  combined  with  nux  vomica. 
Exercise,  Massage,  Lavage,  etc. —  Exercise  should  be  recommended, 
but  so  regulated  as  not  to  interfere  with  digestion.  It  should  be 
postponed  until  digestion  has  been  in  progress  for  at  least  an 
hour  or  two,  and,  when  the  patient's  strength  admits  of  it,  gentle 
horseback  or  bicycle  riding  is  beneficial  for  the  young  and  middle- 
aged.  Otherwise  special  exercises  designed  to  strengthen  the  ab- 
dominal muscles  and  thoracic  respiratory  muscles  may  be  em- 
ployed. 

Massage  of  the  stomach,  performed  two  hours  after  meals,  is  of 
service,  and  early  morning  lavage  is  of  value  when  pyrosis  and  gastric 
distress  occur  so  soon  after  eating  as  to  indicate  active  malfermenta- 
tion. 


CHRONIC  GASTRIC  CATARRH 


595 


SUMMARY  OF  FOODS  FOE  CASES  OF  CHRONIC  GASTRIC  CATARRH  IN 
WHICH  A  FAIRLY  LIBERAL,  DIETARY  IS  PERMISSIBLE 

Fish:  Fresh  fish,  boiled  or  broiled,  as  bass,  whitefish,  whiting, 
sole,  redsnapper,  shad,  weak  fish,  butterfish,  smelt,  perch,  trout,  with 
lemon,  or  a  little  plain  butter  sauce. 

Oysters  (soft  parts  only)  stewed,  broiled  or  panned. 
Eggs,  scrambled,  shirred,  poached  or  soft  cooked. 
Meats:     Eare  roast  beef,  tenderloin  steak,  French  mutton  chops, 
roast    or    boiled    mutton,    lamb,    lean    ham,    crisp    thin-cut    bacon, 
chicken,  broiled  or  roasted,  white  meat  of  turkey,  capon,  guinea  hen, 
grouse,  partridge,  quail,  squab,  tongue,  sweetbread. 
Butter  and  cream,  very  sparingly. 
Saccharin  in  lieu  of  sugar. 

Cereals  in  small  quantity,  trisket,  shredded  wheat,  puffed  rice, 
puffed  wheat,  boiled  rice,  fine  hominy,  stale  wheat  bread,  dry  toast, 
milk  toast,  crackers,  thin  ginger  snaps,  dry  sponge  cake,  zwieback, 
Huntley  and  Palmer  wafers,  pulled  bread. 

Vegetables:  White  potatoes  (sparingly,  baked  or  mashed),  as- 
paragus, artichokes,  string  beans,  young  new  peas,  spinach,  lettuce 
(French  dressing,  not  mayonnaise),  oyster  plant,  squash,  tomatoes 
(stewed  or  raw). 

Desserts:  Bread  or  rice  pudding,  junket,  blancmange,  wine  jelly, 
baked  custard,  Bavarian  cream,  plain  vanilla  ice  cream. 

Fruits:  Apple  sauce,  baked  apples,  stewed  prunes  (without  the 
skins),  oranges,  cantaloupe,  ripe  peaches,  or  plums,  pineapple  juice 
(without  the  fiber.) 

Beverages  (between  meals),  weak  tea,  coffee,  soda  lemonade.  Kou- 
miss, zoolak,  buttermilk. 

From  this  liberal  dietary  it  is  best  to  select  not  more  than  3 
courses  or  half  a  dozen  kinds  of  food  for  one  meal.  This  greatly 
lessens  the  complexity  of  the  digestive  processes. 

FOODS  FORBIDDEN:  Pastry,  pies,  puddings  (except  as  specified 
above)  brown  bread,  hot  bread,  cake,  "  cakes,"  sirup,  candy  and  con- 
fectionery, honey,  sugar,  jams,  marmalade,  preserves,  rich  soups, 
gravies,  sauces,  veal,  pork,  sausage,  pate  de  foie  gras,  canned  foods, 
stews,  hashes,  ragouts,  "stuffing"  of  fowl,  condiments  and  spices, 
mustard,  pickles,  cheese,  mushrooms,  lobster,  crabs,  terrapin,  clams, 
chowder,  herring,  mackerel,  cod,  halibut,  salmon,  sweet  potatoes, 
radishes,  corn,  beets,  baked  beans,  turnips,  carrots,  onions,  cucumbers, 
cabbage,  cauliflower,  horse-radish  Brussels  sprouts,  Lima  beans,  nuts, 
raisins,  berries,  cherries,  banana?,  grapes,  grape  fruit. 


596  DIET  IN  DISEASES  OF  THE  STOMACH 

t 

Chronic  Gastric  Catarrh  in  Children 

Children  with  chronic  gastric  catarrh  should  always  eat  their  prin- 
cipal meal  in  the  middle  of  the  day,  and  take  only  a  light  supper. 

When  of  nervous  temperament,  they  bolt  their  food  without  proper 
mastication.  At  the  age  too,  when  their  deciduous  teeth  are  being 
replaced  they  may  from  time  to  time  have  difficulty  in  eating  solid 
food.  This  matter  should  be  inquired  into,  and  if  necessary  all  such 
food  should  be  minced  before  it  is  given  to  the  child.  Children 
accustomed  to  luxury  usually  overeat,  and  suffer  in  consequence. 
Their  supervision  at  table  is  often  left  to  ignorant  or  careless  serv- 
ants, who  should  be  cautioned,  and  better  heed  will  be  taken  if 
the  instruction  is  given  by  the  physician  rather  than  by  an  indulgent 
mother. 

In  young  children  gastric  lavage  is  easily  performed,  and  may 
be  beneficial,  but  older  children  are  apt  to  *  struggle  and  resist  it. 
The  tube  may  be  passed  as  in  gavage  (see  Gavage),  and  directions 
for  lavage  are  given  on  p.  598.  Their  diet  should  be  restricted 
mainly  to  bread  and  butter,  rice,  chicken,  scraped  beef,  eggs,  cus- 
tards, milk,  baked  potatoes,  milk  toast  and  milk. 

DILATATION  OF  THE  STOMACH  —  GASTRECTASIA 

Causation. —  Dilatation  of  the  stomach  may  result  from  stricture 
of  its  pyloric  end,  or  from  chronic  gastritis,  in  which  case  it  is  ac- 
companied by  the  secretion  of  much  tenacious  mucus.  The  stricture 
may  be  due  to  a  carcinomatous  growth,  hypertrophied  mucous  mem- 
brane caused  by  chronic  gastritis,  or  contracture  following  gastric 
ulcer. 

Gastric  dilatation  is  also  produced  by  loss  of  tone  or  paresis  of 
the  muscular  coat,  destruction  of  the  muscular  coat  due  to  ulcer- 
ation,  and  lack  of  proper  nervous  or  nutritive  supply,  such  as 
results  from  debilitating  illness,  like  typhoid  fever,  tuberculosis,  or 
general  nervous  prostration.  Less  often  it  is  caused  by  abuses  of 
diet,  especially  those  which  give  rise7  to  much  gas  by  excessive  use 
of  effervescing  beverages,  beer,  etc.  The  varieties  due  to  gastritis,  de- 
bility, and  dietetic  errors  are  most  amenable  to  treatment. 

Pathological  Physiology. —  The  food  is  imperfectly  digested  owing 
to  want  of  gastric  juice  and  of  peristalsis  or  to  admixture  with  quan- 
tities of  mucus :  it  therefore  lingers  in  the  stomach  beyond  the  usual 
time,  ferments,  interferes  with  thorough  digestion  of  the  next  meal, 
and  renders  the  chyme  unfit  for  the  intestine.  Food  may  lie  un- 


DILATATION  OF  THE  STOMACH  —  GASTRECTASIA        597 

digested  in  a  dilated  stomach  all  night,  and  be  vomited  with  ac- 
cumulated mucus  in  the  morning  or  perhaps  after  24  hours.  The 
undigested  food  by  its  weight  drags  down  the  stomach  and  favors 
further  dilatation  by  stagnation  and  development  of  gases.  The 
motor  function  of  the  stomach  is  almost  completely  suspended. 

Dietetic  Treatment. —  For  these  reasons  it  is  necessary  to  limit  the 
quantity  of  solid,  and  especially  of  fluid  nourishment.  Nothing  but 
the  simplest  articles  of  diet  should  be  allowed.  All  food  should  be 
given  in  a  concentrated  and  readily  assimilable  form,  so  that  it  will 
either  be  absorbed  directly  from  the  stomach  wall  or  pass  promptly 
into  the  duodenum. 

In  advanced  cases  food  should  be  predigested  as  much  as  possible. 
The  more  concentrated  varieties  should  be  chosen.  Ewald  recom- 
mends the  employment  of  pancreatinized  condensed  milk,  which  is 
very  nutritious  and  of  agreeable  flavor.  It  should  be  condensed  with- 
out addition  of  the  usual  excess  of  cane  sugar,  which  will  surely  fer- 
ment in  the  stomach. 

The  patients  are  often  thirsty,  and,  in  fact,  the  original  dilatation 
may  have  been  caused  by  excessive  imbibition,  but  the  amount  of 
fluid  drunk  with  meals  should  be  restricted  to  four  or  six  ounces,  or 
in  serious  cases  no  fluid  at  all  should  be  allowed  at  mealtimes.  If 
the  thirst  is  considerable,  a  tumblerful  of  hot  water  may  be  taken  a 
half  hour  before  meals,  to  be  absorbed  or  pass  into  the  intestines 
before  the  food  enters  the  stomach.  Water  is  more  quickly  absorbed 
hot  than  cold.  Thirst  may  be  relieved  by  salt  water  enemata,  but 
they  rarely  are  necessary. 

The  proper  diet  for  gastric  dilatation  is  the  same  as  that  recom- 
mended for  serious  cases  of  chronic  gastritis  (p.  590),  except  that  it 
is  more  concentrated  and  smaller  in  bulk,  and  farinaceous  food  is 
almost  entirely  forbidden. 

At  first  only  animal  food  should  be  given,  such  as  scraped  beef, 
beef  juice  or  a  piece  of  broiled  chicken,  with  perhaps  a  very  little  dry 
toast  or  toasted  cracker.  If  vomiting  is  a  persistent  symptom,  the 
patient  may  drink  milk  very  slowly,  taking  crushed  ice  with  each 
mouthful.  Later,  after  from  two  or  three  to  six  weeks,  if  improve- 
ment has  resulted,  more  latitude  is  permissible,  and  the  food  ad- 
vised is  lean  meat  free  from  coarse  fiber;  fresh  vegetables,  such 
as  string  beans,  asparagus,  tender  and  well-cooked  purees,  dry  bread, 
lettuce  or  cress  with  vinegar,  simple  starches,  such  as  sago,  macaroni, 
rice,  tapioca,  and  vermicelli,  boiled  or  broiled  oysters  or  fish,  soft- 
cooked  eggs,  orange  juice,  stewed  or  baked  apples  without  sugar, 
stewed  prunes.  Some  patients  may  drink  a  tumblerful  of  boiled 


598  DIET  IN  DISEASES  OF  THE  STOMACH 

milk  between  meals,  but,  as  a  rule,  it  is  best  to  take  nothing.  There 
should  never  be  more  than  three  meals  a  day,  at  six  hour  intervals, 
and  some  patients  do  better  with  only  two.  In  mild  cases,  coffee  and 
tea  without  sugar  are  allowed. 

To  be  avoided  are  most  forms  of  starchy  food,  and  sugar,  pota- 
toes, old  peas,  beans,  corn.  Fruit  consists  largely  of  water  in  pro- 
portion to  its  nutritive  value,  and  its  vegetable  acids  are  likely  to 
disagree.  It  should  therefore  be  eaten  sparingly.  Fats,  butter,  and 
oils  are  not  digested  in  the  stomach.  Thirst-exciting  foods,  as  salt 
fish,  should  not  be  taken,  nor  beer,  effervescing  mineral  waters,  red 
wine,  or  thin  soups. 

In  all  cases  too  long  continuance  of  a  very  strict  diet  is  liable  to 
cause  the  patient  or  the  stomach  itself  to  rebel.  The  patient  should 
be  weighed  once  a  week.  The  stools  should  be  examined  and  the 
general  nutrition  carefully  considered.  If  weight  is  rapidly  lost,  the 
food,  whatever  it  may  be,  is  not  being  assimilated,  and  should  be 
changed.  It  may  become  necessary  to  disregard  the  rules  for  fluid 
and  put  the  patient  for  a  time  upon  a  diet  of  predigested  milk. 

Aids  to  Dietetic  Treatment. —  Other  means  of  treatment  which  are 
really  adjuncts  to  dietetic  measures  should  be  recommended.  Such 
are  lavage,  massage,  and  electricity,  which  will  be  considered  below. 
Mucus,  especially  that  which  is  accumulated  overnight,  may  be  washed 
out  of  the  stomach  by  sipping  a  cup  of 'very  hot  water  or  taking 
alkaline  mineral  water,  or  a  pint  of  water  with  ten  grains  of  bicarbo- 
nate of  soda,  on  rising. 

It  is  desirable  for  the  patient  to  lie  down  for  an  hour  and  a  half 
after  eating,  and  he  should  especially  avoid  mental  and  bodily  fatigue, 
which  tend  to  divert  both  nerve  energy  and  the  blood  from  the  func- 
tions of  digestion. 

Lavage. —  In  cases  of  either  dilatation  or  catarrh  of  the  stomach 
which  fail  to  improve  on  restricted  diet  and  other  methods  of  treat- 
ment, lavage  or  stomach  washing  becomes  necessary.  This  is  an 
entirely  safe  procedure,  and  one  to  which  patients  become  readily 
accustomed,  provided  sufficient  tact  and  care  is  employed  when  the 
method  is  first  applied.  It  was  first  practiced  by  Kussmaul  in  1867. 
It  should  be  attempted  in  all  serious  cases  in  which  other  methods  to 
relieve  the  patient  have  been  already  tried  and  failed.  It  is  almost 
indispensable  in  those  cases  in  which  the  atony  of  a  greatly  distended 
stomach  wall  prevents  the  food  from  being  expelled  into  the  in- 
testine, causing  constant  fermentation,  or  in  cases  in  which  decom- 
posing food  passes  into  the  duodenum,  exciting  dyspepsia,  meteorism, 
and  diarrhoea. 


DILATATION  OF  THE  STOMACH  —  GASTRECTASIA       599 

As  many  as  sixteen  varieties  of  bacteria  have  been  obtained  from 
the  washings  of  a  dilated  stomach  in  which  food  had  been  stagnating. 

The  advantages  of  lavage  are  twofold;  it  not  only  removes  irri- 
tating and  fermenting  material  from  the  stomach,  and  the  ropy, 
tenacious  mucus  which  it  contains,  and  allays  vomiting,  but  the 
water  applied  to  the  mucous  membrane  cleanses  it  and  stimulates  the 
gastric  glands  to  normal  secretion  and  the  stomach  wall  to  contrac- 
tion. It  also  promotes  more  regular  action  of  the  bowels. 

The  relief  from  the  sensations  of  weight,  oppression,  discomfort, 
and  nausea  which  is  promptly  experienced  after  lavage  is  usually 
immediate  and  lasts  for  several  hours.  It  is  so  great  that  patients 
not  infrequently  learn  to  pass  the  cesophageal  catheter  themselves, 
and,  holding  a  pitcher  of  warm  water  in  one  hand  and  a  funnel  in 
the  other,  they  wash  and  siphon  out  their  own  stomachs  with  ease. 
Usually  it  is  sufficient  to  wash  the  stomach  once  a  day.  In  extreme 
cases  it  may  be  necessary  to  perform  the  operation  twice  a  day,  but 
when  improvement  is  once  established,  washing  may  be  limited  to 
every  other  day  or  may  be  employed  occasionally,  according  to  need, 
but  it  should  be  continued  for  several  weeks  after  the  subsidence  of 
all  symptoms.  As  a  result  of  this  treatment,  the  stomach  may 
diminish  in  size,  and  the  food  is  better  digested  and  more  completely 
absorbed,  while  nutrition  and  assimilation  are  correspondingly  im- 
proved. 

The  best  time  for  digestion  of  the  principal  meal  of  the  day  is 
within  an  hour  after  lavage,  when  the  stomach  is  empty  and  thor- 
oughly cleansed,  and  the  meal  often  may  be  assimilated  completely. 
If  decided  repugnance  to  food  exists,  the  tube  may  be  used  for  forced 
feeding,  and  peptones  and  predigested  milk  and  eggs  may  be  poured 
in  before  it.  is  withdrawn  from  the  stomach,  although,  as  stated  above, 
it  is  best  that  too  much  fluid  food  should  not  be  given. 

In  performing  lavage  a  medium-sized  cesophageal  tube  should  be 
selected,  about  one-third  of  an  inch  in  diameter,  having  two  or  three 
large  smooth  eyes  or  "velvet"  fenestra  and  made  of  good,  smooth, 
red  rubber  which  is  sufficiently  flexible  without  being  so  easily  bent 
as  to  allow  the  tube  to  double  upon  itself  in  its  passage.  This  tube 
should  be  fully  eighteen  inches  long,  and  it  is  attached  to  a  length 
of  three  feet  of  common  rubber  tubing  by  means  of  a  small  glass 
tube;  the  other  extremity  of  the  rubber  tubing  is  fastened  to  a  fun- 
nej  through  which  warm  water  is  poured  into  the  stomach.  A  glass 
funnel  is  preferred,  which  makes  it  easier  to  examine  the  washings 
as  they  return.  The  patient  is  cautioned  to  keep  the  head  thrown 
back,  and  the  tube  is  gently  pushed  over  the  dorsum  of  the  tongue 


600  DIET  IN  DISEASES  OF  THE  STOMACH 

and  along  the  posterior  pharyngeal  wall  into  the  oesophagus.  The  inser- 
tion of  the  tube  will  be  facilitated  by  moistening  it  with  water,  white 
of  egg  or  milk. 

If  there  is  any  difficulty  in  introducing  the  tube,  its  downward 
passage  may  be  aided  by  passing  the  forefinger  to  the  back  of  the 
pharynx.  If  the  patient,  who  either  sits  or  stands,  be  instructed  to 
make  an  effort  at  swallowing  while  the  tube  is  being  inserted  it 
will  descend  much  easier,  and  pains  should  be  taken  to  explain  the 
process  and  reassure  him,  for  nervousness  and  struggling  may  excite 
spasms  of  the  laryngeal  muscles  and  make  it  difficult  or  impossible 
to  pass  the  tube.  On  reaching  the  cardiac  end  of  the  stomach,  the 
tube  is  occasionally  stopped  for  a  moment,  but  the  patient  should 
be  instructed  to  try  and  swallow,  and  with  gentle  pressure  the  orifice 
soon  relaxes  and  the  tube  enters  the  stomach.  Or  a  little  water 
poured  into  the  tube  may  cause  the  cardia  to  relax.  The  funnel  is 
raised  above  the  patient's  head,  but  before  pouring  in  much  fluid  it 
should  be  ascertained  that  he  is  able  to  breathe  comfortably  and 
quietly  when  the  tube  is  momentarily  compressed.  He  should  be 
reassured  that  he  will  not  choke.  Accidents  have  occasionally  hap- 
pened from  passing  small  tubes  down  into  the  larynx,  and  I  have 
known  of  one  fatal  case  in  which  a  nasal  tube  was  thus  passed  and 
milk  was  poured  into  the  lungs.  A  case  has  been  reported  in  which 
beef  tea  was  poured  into  the  lungs  in  this  manner,  but  the  patient 
recovered  and  the  beef  tea  was  coughed  up  or  absorbed.  There  is 
very  little  danger  of  introducing  an  cesophageal  tube  of  the  ordinary 
size  in  the  wrong  direction,  for  any  attempt  to  push  it  into  the 
pharynx  will  be  met  by  obstruction  and  spasmodic  coughing.  If 
the  stomach  is  full  when  the  tube  is  first  passed,  some  of  the  contents 
may  be  siphoned  out  immediately  by  lowering  the  funnel  below  the 
stomach  level  and  holding  it  over  a  ^oot-tub  or  pail.  If  neces- 
sary, water  may  be  poured  in  gently  to  the  extent  of  a  quart,  or 
until  the  patient  complains  of  uncomfortable  fullness  in  the  stomach. 
Care  should  be  exercised  not  to  admit  air  bubbles.  The  tube  and 
funnel  are  then  inverted  over  a  foot  basin  and  the  contents  of  the 
stomach  are  quickly  siphoned  out.  This  procedure  may  be  repeated 
a  number  of  times  until  all  the  food  and  mucus  have  been  removed 
and  the  washings  return  quite  clear  and  neutral  in  reaction.  The 
quantity  of  water  used  in  the  washing  should  be  measured  so  that 
it  all  may  be  siphoned  out  again,  as  it  is  undesirable  to  leave  any 
fluid  behind. 

When  the  tube  is  introduced  for  the  first  few  times  it  may  excite 
efforts  at  vomiting,  but  it  is  not  necessary  to  remove  it,  for  the  pa- 


DILATATION  OF  THE  STOMACH  —  GASTRECTASIA        601 

tient  can  usually  regurgitate  the  long,  stringy  mucus  alongside  of 
it.  Salivation  is  often  produced  in  the  first  few  trials.  After  two 
or  three  passages  patients  will  learn  to  swallow  the  tube  with  very 
little  assistance  and  cease  to  gag  upon  its  introduction.  If  there 
is  hyperassthesia  of  the  pharynx  the  pharyngeal  wall  may  be  touched 
with  a  4-per-cent  cocaine  solution  just  before  the  introduction  of 
the  tube,  or  several  large  doses  of  bromide  of  potassium  may  be 
administered  during  the  previous  twenty-four  hours.  If  nausea  oc- 
curs when  the  tube  first  reaches  the  cardia  it  is  usually  overcome  by 
pouring  in  a  little  fluid.  The  success  of  the  operation  at  the  first 
trial  depends  largely  upon  the  skill  of  the  physician  and  the  degree 
to  which  he  has  obtained  the  confidence  of  his  patient,  and  has  been 
able  to  overcome  any  nervous  feeling  in  regard  to  a  process  which  is 
at  best  highly  disagreeable.  After  the  sufferer  from  gastric  dilata- 
tion has  experienced  the  relief  which  lavage  of  the  stomach  can  give, 
he  usually  requires  no  urging  to  allow  the  process  to  be  repeated. 
In  withdrawing  the  tube  it  should  be  compressed  in  order  to  avoid 
having  any  of  its  contents  trickle  into  the  larynx;  in  this  manner 
retching  is  less  likely  to  ensue. 

The  fluid  used  for  washing  the  stomach  may  be  either  cool,  or 
very  hot  water.  Hot  water  is  best,  and  it  is  well  to  sterilize  it  by 
previous  boiling.  If  much  mucus  is  present  or  much  acidity,  sodium 
bicarbonate  may  be  added  in  the  proportion  of  two  or  three  per 
cent  (15  grains  to  the  pint),  or  a  similar  quantity  of  sodium  borate 
or  boric  acid,  a  one-half-per-cent  solution  of  salicylic  acid,  or  a  1-per- 
cent solution  of  sodium  salicylate. 

The  best  time  for  conducting  lavage  is  shortly  before  the  midday 
meal,  the  patient  having  had  a  very  light  breakfast,  and  it  should 
only  be  performed  when  the  stomach  is  believed  to  be  comparatively 
empty.  If  the  tube  is  introduced  before  breakfast,  having  had  noth- 
ing to  eat  for  a  number  of  hours,  patients  are  more  apt  to  be  dis- 
agreeably affected,  especially  if  the  washing  be  long  continued,  and 
I  have  seen  them  become  faint  under  these  circumstances.  It  is 
better,  therefore,  that  a  light  breakfast  of  bread  and  milk,  pancreatin- 
ized  milk,  or  of  a  scraped-beef  sandwich  and  a  cup  of  black  coffee 
should  be  taken;  three  hours  later  the  stomach  is  to  be  washed. 
There  are  exceptional  cases  in  which  the  patient  is  so  distressed  by 
the  effort  to  pass  the  tube  or  by  the  operation  of  rinsing  the  stomach 
itself  that  it  has  to  be  abandoned.  Lavage  should  be  avoided  in 
cases  complicated  by  much  prostration,  feeble  heart  action,  aneurism, 
hgematemesis,  or  haemoptysis. 

Accessory  measures  which  are  to  be  used  in  connection  with  lavage 


602  DIET  IN  DISEASES  OF  THE  STOMACH 

and  careful  regulation  of  diet  are  massage  of  the  stomach,  and 
medicinal  treatment  which  consists  largely  of  the  administration  of 
tonics,  especially  strychnine  or  nux  vomica,  with  the  object  of  increas- 
ing the  muscular  action  of  the  stomach. 

Massage. —  Gastric  massage  should  be  performed  about  two  and 
a  half  or  three  hours  after  each  meal  for  ten  minutes.  The  patient 
lies  upon  his  back,  with  knees  drawn  up  and  muscles  relaxed.  The 
movements,  stroking  and  kneading,  always  should  be  made  over  the 
stomach  in  the  direction  of  the  pylorus.  If  not  too  weak,  the  pa- 
tient may  be  taught  to  perform  these  movements  himself.  This  treat- 
ment is  often  of  considerable  aid  in  mixing  the  food  and  gastric  juice 
and  in  propelling  the  food  into  the  intestine.  It  increases  peristalsis. 

Electricity. —  Faradization  of  the  stomach  is  believed  by  many 
to  increase  its  muscular  tone,  and  various  forms  of  electrodes  have 
been  devised  for  this  purpose.  It  is  probable  that  very  little,  if  any, 
electric  stimulation  reaches  the  stomach  when  currents  of  ordinary 
strength  are  applied  over  the  epigastrium,  although  Ewald  and 
Sievers  claim  that  it  does  in  some  cases.  This  is  especially  true  of 
faradism.  Canstatt  first  proposed  to  apply  the  current  directly  within 
the  stomach  wall,  and  methods  have  been  devised  by  Bardet,  Einhorn, 
and  others  to  serve  this  purpose. 

The  ingenious  electrode  invented  by  Einhorn,  of  New  York,  is 
easily  passed  into  the  stomach.  It  consists  of  a  hard-rubber  capsule 
about  the  size  of  a  small  French  olive.  The  hollow  capsule  has 
numerous  perforations  and  within  it  is  a  small  metallic  electrode. 
The  capsule  is  fastened  to  a  fine  flexible  conducting  wire,  which  is 
attached  to  the  battery,  and  the  wire  is  protected  by  a  minute  soft- 
rubber  tube  one  inch  in  diameter.  This  electrode  is  readily  swallowed 
by  placing  it  upon  the  dorsum  of  the  tongue  and  then  drinking  water. 
About  16  inches  of  the  wire  should  be  swallowed.  In  withdrawing 
the  electrode  after  use  it  sometimes  catches  at  the  cardiac  end  of 
the  stomach,  but  if  the  patient  swallows  a  little  water  it  slips  past. 
When  this  electrode  is  in  the  stomach,  which  previously  has  been 
filled  partially  with  a  pint  or  more  of  warm  saline  solution,  the  second 
electrode,  broad  and  flat,  is  placed  over  the  epigastrium  or  over  the 
back  to  the  left  of  the  seventh  dorsal  vertebra,  and  the  electric  cur- 
rent is  turned  on. 

This  treatment  is  designed  especially  to  increase  the  muscular  tone 
of  the  stomach  in  atonic  dilatation  and  stimulate  peristalsis,  but  it 
also  serves  to  promote  secretion,  and  hence  it  doubly  aids  digestion. 
The  electric  current  may  be  applied  daily,  immediately  after  lavage, 
for  ten  or  fifteen  minutes,  and  should  be  strong  enough  to  induce 


VOMITING  603 

active  peristalsis.     Even  patients  who  are  not  accustomed  to  lavage 
seldom  object  to  swallowing  the  electrode. 

Medicines. —  A  variety  of  medicinal  remedies  are  also  used  »with 
the  object  of  preventing  fermentation  of  food  in  the  stomach  and 
intestine  and  for  artificially  aiding  digestion  by  these  organs.  Among 
the  former  are  to  be  mentioned  creosote  and  other  substances  allied 
to  carbolic  acid,  naphthaline,  salicylic  acid,  etc.  The  use  of  hydro- 
chloric acid  has  been  mentioned  in  connection  with  chronic  gastric 
catarrh  (p.  594). 

VOMITING  — SEASICKNESS  — VOMITING  IN  PREG- 
NANCY 

Vomiting  occurs  as  a  symptom  of  so  many  diseases  and  func- 
tional derangements  that  it  will  be  advantageous  to  consider  col- 
lectively the  general  dietetic  means  for  its  relief.  The  details  of 
treatment  will  be  explained  under  the  headings  of  the  various  dis- 
eases in  which  vomiting  may  become  a  serious  or  prominent  symptom. 

Pathological  Physiology. —  Vomiting  as  related  to  dietetics  may  be 
caused  by:  1.  Excess  of  food.  2.  Foods  and  drinks  improperly 
combined  (as  crabs  and  milk,  beer  and  champagne,  etc.).  3.  Fer- 
menting or  poisonous  food.  4.  Irritating  and  indigestible  food,  in- 
cluding that  which  is  improperly  cooked.  5.  Hastily  eaten  food. 

In  hysterical  patients  and  in  very  neurotic  conditions  of  the  sys- 
tem, either  the  sight,  taste,  smell,  or  mental  suggestion  of  food  may 
excite  nausea  and  vomiting. 

Instances  of  the  influence  of  the  mind  over  stomach  digestion  and 
the  mechanism  of  vomiting  are  too  familiar  to  need  elaboration. 
Food  which  is  in  itself  nourishing  may  promptly  nauseate  through 
disgusting  association  or  environment.  For  example,  a  party  of 
early  California  settlers  while  crossing  the  continent  were  lost  dur- 
ing a  severe  winter  in  the  Sierras.  When  nearly  dead  of  starvation 
some  friendly  Indians  took  compassion  and  fed  them  upon  a  delicious 
finely  ground  meal,  which  for  some  days  was  their  staple  article  of 
diet,  and  on  which  they  rapidly  gained  strength  and  weight.  Being 
at  first  unable  to  understand  the  Indians,  the  emigrants  could  not 
learn  of  what  the  meal  was  composed.  When  at  length  they  found 
that  it  was  made  from  pounded  dried  grasshoppers  it  produced  such 
nausea  that  none  could  touch  the  food  again. 

Dietetic  Treatment. —  The  first  principle  in  the  dietetic  treatment 
of  vomiting  from  any  cause  is  to  give  the  stomach  rest.  If  it  has 
been  overloaded  with  a  large  bulk  of  food,  or  with  indigestible  ma- 


604  DIET  IN  DISEASES  OF  THE  STOMACH 

terial,  it  is  well  to  encourage  emesis,  and  distressing  retching  may 
be  overcome  by  taking  large  draughts  of  lukewarm  water.  A  quart 
or  two  will  rinse  out  the  stomach  and  allay  irritation  to  a  marked 
degree. 

Well-nourished  patients  when  serious  vomiting  first  occurs  should 
usually  refrain  from  taking  food  of  any  kind  for  from  ten  or 
twelve  to  twenty-four  hours.  Exceptions  to  this  rule  are  some- 
times found  in  that  type  of  seasickness,  and  sometimes  in  the  vomiting 
of  pregnancy,  in  which,  as  soon  almost  as  the  stomach  is  emptied, 
there  is  a  desire  to  replenish  the  loss. 

In  any  case  in  which  gastric  irritation  is  persistent  it  is  necessary 
to  give  fluid  food,  and  only  in  small  oft-repeated  doses,  preferably 
in  predigested  form.  The  food  is  best  given  cold,  as  a  rule,  although 
some  persons  can  relieve  nausea  by  sipping  very  hot  water. 

A  teaspoonful  of  pancreatinized  milk,  or  in  extreme  cases  a  few 
drops  only,  given  with  a  medicine  dropper  once  in  ten  or  fifteen  min- 
utes, may  be  all  that  the  stomach  will  tolerate  at  first. 

The  following  is  a  list  of  dietetic  substances  which  are  commonly 
prescribed  for  the  relief  of  nausea  and  vomiting,  or  for  nourishment 
while  those  conditions  exist :  Cracked  ice ;  pancreatinized  milk ;  milk 
with  sodium  bicarbonate  (ten  grains),  and  cerium  oxalate  (five 
grains) ;  milk  and  lime  water  in  equal  parts;  milk  and  Vichy,  soda, 
Seltzer,  or  carbonic-acid  water;  whey;  koumiss  and  zoolak;  beef  ex- 
tracts and  peptonoids,  such  as  Johnson's  Fluid  Beef  and  Carnrick's 
Beef  Peptonoids,  somatose,  Valentine's  or  Liebig's  meat  juice;  raw 
meat  pulp,  scraped;  strong  black  coffee;  sour  lemonade  or  lemonade 
and  Vichy;  clam  broth.  Dry  crackers,  dry  toast,  and  gingersnaps 
will  sometimes  be  retained  in  seasickness,  or  a  cracker  buttered  and 
sprinkled  with  a  little  Cayenne  pepper;  brandy  and  soda;  iced  dry 
champagne;  iced  brandy  diluted  with  water,  plain  soda  water,  or 
Apollinaris,  Imperial  Granum. 

Severe  and  protracted  cases  may  require  lavage  or  nutrient  enemata. 
Vomiting  after  abdominal  surgical  operations  is  often  controlled  by 
lavage. 

Recurrent  or  "  cyclic  "  vomiting  is  a  gastric  neurosis  due  to  proteid 
putrefaction  in  the  intestine,  or  possibly  to  an  acidosis,  occurring 
usually  in  young  children  up  to  the  twelfth  year.  The  vomiting  re- 
sults from  overexcitement,  or  fatigue,  and  occurs  irrespective  of  the 
ingestion  of  food.  The  attacks  are  accompanied  by  serious  prostra- 
tion, and  often  for  a  day  or  two  no  food  whatever  can  be  retained. 
In  such  cases  rectal  feeding  may  be  resorted  to  (p.  455)  with  pep- 
tonized  milk.  When  the  vomiting  has  been  quieted  by  rest  and 


SEASICKNESS  605 

medicinal  measures,  feeding  per  os  should  be  resumed  with  gruels, 
vegetable  purees,  rice,  etc.,  and  proteid  foods  should  not  be  given 
until  the  child  is  well,  and  then  very  sparingly.  To  avoid  future 
attacks,  it  is  well  for  the  child  once  a  month  to  be  placed  on  a 
modified  vegetarian  diet  with  cereals,  green  vegetables,  potatoes  and 
fruits  for  a  week,  and  then  resume  ordinary  meals.  By  this  alterna- 
tion of  diet,  combined  with  prevention  of  fatigue  and  excitement,  es- 
pecially during  the  hours  of  digestion,  the  recurrent  attacks  may  be 
avoided,  or  lessened. 

Seasickness 

There  is  no  known  dietetic  treatment  of  seasickness  which  is  ap- 
plicable to  all  cases.  There  are  those  who  overeat  because  of  the 
tonic  of  the  bracing  sea  air.  The  idleness  and  lack  of  accustomed 
exercise,  and  perhaps  something  in  the  quality  of  the  air  itself,  all 
contribute  to  make  them  bilious,  and  unloading  stomach  and  bowels 
thoroughly  once  for  all  suffices  to  cure  them  for  the  rest  of  the  voy- 
age. The  habit  of  indulging  in  late  "  farewell  suppers  "  is  naturally 
the  worst  preparation  possible  for  a  sea  voyage. 

Some  persons  at  sea  can  leave  the  table,  vomit  the  first  two  or 
three  courses  of  a  dinner,  return,  and  finish  the  meal  with  astonish- 
ing equanimity.  With  them  nausea  is  not  a  persistent  or  annoying 
symptom,  and  they  need  no  treatment.  Others  are  always  nauseated, 
but  fail  to  vomit,  and  consequently  grow  weak  from  lack  of  food. 
They  do  well  to  take  a  mild  emetic  at  first,  and  usually  a  tumblerful 
of  lukewarm  water  will  serve  to  empty  the  stomach  of  food  lying 
there  undigested  and  fermenting.  They  are  then  temporarily  re- 
lieved, and  may  assimilate  some  form  of  predigested  food. 

Others,  after  severe  experience  with  emesis,  strongly  crave  and 
<?an  actually  retain  and  digest,  in  defiance  of  all  dietetic  laws, 
substances  which  they  could  scarcely  eat  at  home.  Old  cheese,  nuts 
and  raisins,  sour  pickles,  canned  lobster,  and  similar  incongruities  of 
•diet  are  indulged  in  without  a  qualm. 

There  is  a  class  of  persons  of  both  sexes,  though  the  greater 
number  are  women,  who  become  so  ill  at  sea  as  to  reach  a  serious 
condition  of  prostration.  These  patients  are  constantly  nauseated, 
not  alone  by  the  taste,  but  by  the  sight  and  odor  of  food.  The 
mere  idea  of  it,  as  the  suggestion  from  reading  an  elaborate  menu, 
will  cause  retching.  It  is  often  difficult  for  such  patients  on  a 
crowded  steamer  to  obtain  the  proper  food  and  service,  and  it  is  well 
for  them  to  go  provided  with  certain  articles  which  are  most  useful. 
Chief  among  these  is  sterilized  milk.  This  is  now  easily  obtainable 


606 

before  sailing,  and  there  is  no  difficulty  in  keeping  it  fresh  during 
the  length  of  an  ordinary  transatlantic  voyage.  It  may  be  peptonized 
at  the  time  it  is  needed,  or  diluted  with  equal  parts  of  Vichy  or  lime 
water,  or  taken  with  ten  grains  of  bicarbonate  of  soda  and  three 
grains  of  cerium  oxalate  to  the  tumblerful.  The  Swiss  milk,  con- 
densed without  sugar,  also  may  be  used.  Fresh  lemons  and  sour 
oranges  are  acceptable  to  many  patients,  the  former  particularly  so 
on  account  of  their  greater  acidity  and  special  power  to  quiet  the 
nausea  of  seasickness.  The  juice  of  one  or  two  lemons,  squeezed 
into  a  tumbler  of  iced  Vichy  or  Apollinaris,  with  a  little  sugar  or 
saccharin,  and  a  pinch  of  bicarbonate  of  sodium,  makes  a  most  re- 
freshing and  soothing  beverage.  Orange  or  lime  juice  may  be  pre- 
ferred. The  latter  may  be  obtained  in  tablet  form. 

Prepared  clam  broth,  like  milk,  may  also  be  carried  in  bottles,  and 
it  often  allays  nausea.  It  is  mildly  stimulating  and  nourishing. 

Other  beverages  which  are  recommended  besides  those  above  men- 
tioned are  weak  brandy  and  soda  or  Seltzer,  cold  champagne,  or 
sparkling  Moselle.  Too  much  ice  water  should  not  be  drunk,  but 
cracked  ice  may  be  sucked.  Strong  black  coffee  is  excellent.  If 
there  is  uncertainty  about  this  being  obtained  good  at  sea,  the  ex- 
tract of  coffee  may  be  carried,  which  may  be  drunk  diluted  in  hot 
water.  Coffee  distinctly  allays  nausea,  besides  being  a  good  cardiac 
stimulant  and  diuretic.  Some  persons  can  take  porter  or  stout  in 
small  doses  with  benefit. 

It  is  not  well  to  take  too  much  soup  or  broth  at  once,  for  if  there 
is  much  motion  the  weight  of  the  fluid,  tipping  about  in  the  stomach 
as  the  vessel  rolls  and  pitches,  may  accentuate  the  nausea.  In  some 
cases  patients  may  retain  dry,  solid  food  better  than  liquids,  and 
they  should  try  soda  crackers,  zweiback,  lemon  gingersnaps,  and 
chipped  smoked  beef,  which  may  be  obtained  in  boxes  at  the  grocer's 
before  sailing.  In  extreme  cases  it  may  be  necessary  to  use  beef 
peptonoids,  meat  extracts  (p.  138),  or  other  meat  preparations,  such 
as  beef  meal,  given  either  by  mouth  or  in  enemata.  The  white  of 
egg  may  be  given  in  brandy.  Preserved  dry  ginger  helps  some 
persons. 

Epigastric  applications  of  hot-water  bags  or  mustard  pastes  afford 
relief,  and  a  large  abdominal  binder  tightly  laced  is  helpful.  It  is 
desirable  to  lie  down  at  once  after  taking  food,  perfectly  horizontal, 
without  a  pillow.  It  is  very  important  to  keep  the  bowels  freely 
open  with  bitter  water  of  some  sort.  Eubinat  is  less  objectionable  in 
taste  than  others.  Seidlitz  powders  are  usually  well  retained,  and  so 
is  citrate  of  magnesia. 


ULCER  OF  THE  STOMACH  607 

Vomiting  of  Pregnancy 

The  vomiting,  of  pregnancy  usually  takes  the  form  of  simple 
"  morning  sickness."  This  may  not  appear  until  the  patient  arises 
in  the  morning,  when  she  feels  faint,  dizzy,  and  nauseated.  Such 
patients  are  benefited  by  remaining  in  bed  until  a  glass  of  milk,  or  a 
cup  of  warm  broth  with  a  biscuit,  or  a  cup  of  cocoa  or  coffee  and  a 
sandwich  has  been  taken  and  digested.  There  may  then  be  no  re- 
turn of  nausea  during  the  day,  but  the  diet  should  at  all  times  be 
simple,  especially  the  last  meal  of  the  day,  and  all  richly  cooked 
food,  pastry,  sweets,  sauces,  and  elaborate  "  made  dishes  "  should  be 
avoided.  Beyond  this  such  patients  may  need  no  further  treatment. 

In  other  women  the  nausea  is  more  persistent,  and  in  the  severest 
cases  the  symptom  is  very  difficult  to  control  by  any  therapeutic 
or  dietetic  measures. 

Such  cases  are  to  be  treated  on  the  lines  suggested  above  for  the 
cure  of  vomiting  in  general  and  for  severe  seasickness.  Nutrient 
enemata  should  be  resorted  to  early  if  there  is  any  sign  of  failing 
strength,  and  before  a  patient  is  allowed  to  die  of  inanition  artificial 
delivery  is  necessitated.  Such  extreme  cases  are  fortunately  very 
rare. 

The  treatment  of  other  forms  of  vomiting  is  considered  under  the 
headings  of  Alcoholism  (p.  440),  Acute  Gastritis  (p.  587),  Chronic 
Gastritis  (p.  590),  and  Dilatation  of  the  Stomach  (p.  597). 

ULCER  OF  THE  STOMACH 

In  ulcer  of  the  stomach  there  is  danger  of  irritation  of  the  abraded 
surface  through  either  the  chemical  or  mechanical  action  of  the  food. 
Excessive  secretion  of  gastric  juice  is  believed  to  be  similarly 
irritating.  In  serious  cases  where  the  ulcer  is  extensive  or  where  it 
is  deep  and  the  stomach  wall  is  thinned,  there  is  liability  of  rupture 
being  caused  by  overdistention  or  an  undue  degree  of  peristaltic  ac- 
tion. In  the  normal  relaxed  condition  of  the  stomach  wall  the 
mucous  membrane  is  folded  into  rugse,  but*  when  it  is  slightly  dis- 
tended the  surface  is  smoothed  out,  and  a  greater  degree  of  stretching 
may  rupture  an  ulcer  which  is  on  the  point  of  perforation,  but  which 
might  still  heal  over  if  the  tension  were  not  too  great.  Further 
danger  from  the  presence  of  ulcer  of  the  stomach  lies  in  the  fact 
that  small  blood  vessels  occasionally  may  be  eroded,  giving  rise  to 
profuse  hemor  hage,  and  any  food  which  irritates  the  surface  of  the 
ulcer  increases  this  risk. 


608  DIET  IN  DISEASES  OF  THE  STOMACH 

Dietetic  Treatment. —  For  these  reasons,  if  the  patient  is  seen  soon 
after  the  occurrence  of  gastric  hemorrhage,  it  is  necessary  to  with- 
hold all  alimentation  from  the  mouth  and  nourish  the  patient  ex- 
clusively upon  nutrient  enemata  (p.  455).  This  treatment  permits 
the  stomach  to  remain  relaxed,  and  it  is  not  stimulated  to  peristalsis 
or  secretion  of  irritating  gastric  juice. 

In  addition  to  the  ordinary  nutrient  enemata  it  may  be  advisable 
twice  a  day  to  give  rectal  injections  of  a  pint  of  salt  water  (31 —  Oi), 
which  by  its  absorption  prevents  thirst  and  relieves  the  patient  of 
the  craving  for  swallowing  liquid,  which  might  result  in  exciting 
further  vomiting.  In  critical  cases,  if  the  irritability  of  the  stomach 
continues  or  the  hemorrhage  is  repeated,  it  becomes  necessary  to 
continue  the  rectal  •  alimentation  for  many  days,  and  patients  may 
live  upon  it  comfortably  for  a  week  or,  in  some  cases,  much  longer. 

Lavage  has  been  employed  successfully  when  vomiting  and  pain 
in  the  stomach  were  uncontrollable,  but  one  usually  hesitates  in 
adopting  this  practice  on  account  of  the  possible  danger  of  pushing 
the  cesophageal  tube  through  the  weakened  wall  of  the  stomach, 
and  I  have  known  of  one  case  which  resulted  fatally  from  this 
procedure,  where  the  stomach  wall,  however,  was  already  eroded 
through  both  the  mucous  and  muscular  layers,  and  perforation  in 
any  event  was  imminent. 

Debove  recommends  the  use  of  the  cesophageal  tube  for  gavage 
when  vomiting  is  persistent  and  nutrient  enemata  are  not  satisfactorily 
retained.  The  tube  should  be  passed  as  far  as,  but  not  necessarily 
into,  the  stomach,  and  fluid  food  is  poured  through  it.  The  act  of 
swallowing  is  thus  avoided,  and  emesis  is  less  likely  to  follow.  If 
the  tube  proves  irritating  its  use  should  not  be  insisted  upon. 

Generally  speaking,  however,  after  a  day  or  two  of  complete  rest 
the  condition  of  the  stomach  will  admit  of  the  gradual  resumption 
of  mouth  feeding,  but  nourishment  should  be  given  exclusively  in 
liquid  and  predigested  form. 

At  first  very  small  quantities,  not  exceeding  one  or  two  teaspoon- 
fuls,  should  be  offered  at  one  time,  and  the  effect  in  regard  to 
nausea  or  vomiting  carefully  observed.  Later,  from  four  to  six 
ounces  should  be  given  every  two  hours.  For  those  cases  of  ulcer 
of  the  stomach  in  which  patients  are  allowed  to  take  food  per  os, 
a  milk  diet  will  usually  agree  the  best,  provided  precautions  are 
observed  against  the  formation  of  large  curds  in  the  stomach,  which 
are  exceedingly  irritating.  The  milk  should  be  given*  in  any  form 
in  which  it  is  best  borne,  and  the  reader  is  referred  to  the  article 
upon  the  modes  of  preparing  milk  and  rendering  it  digestible  (p.  86). 


ULCER  OF  THE  STOMACH  609 

Da  Costa  found  that  plain  ice  cream  gave  unexpected  relief  in  some 
cases.  Some  patients  do  well  upon  koumiss,  buttermilk,  or  zoolak. 
Karl  Eniil  Ewald  advocates  the  use  of  milk  thickened  with  flour  of 
various  kinds  to  prevent  the  formation  of  large  coagulae.  The  pre- 
digested  starchy  infant  foods,  such  as  Nestles,  Mellin's,  Imperial 
Granum,  or  malted  milk,  may  be  added,  but  gruels  made  with  coarse 
cereals  are  not  permissible. 

When  milk  preparations  fail,  it  is  unwise  to  persist  in  giving 
them,  and  teaspoonful  doses  of  pancreatinized  beef  juice  should  be 
substituted,  or  peptonized  solutions.  Other  patients  may  be  fed  upon 
egg  albumen  beaten  and  sweetened  or  prepared  with  sherry  wine,  or 
the  yolk  of  an  egg  may  be  beaten  in  an  ounce  of  boiling  water  and 
added  to  a  tumbler  of  milk.  Less  serious  cases  may  be  allowed  such 
articles  as  zwieback  or  stale  bread  crumbs  or  cracker  crumbs  soaked 
in  milk  and  until  quite  soft,  which  will  prevent  the  formation  of 
large  coagulse  of  milk.  One  of  the  various  malt  preparations  may 
be  well  tolerated  and  prove  nutritious.  Leube's  Soluble  Meat  is  a 
preparation  which  relieves  the  stomach  of  all  necessary  work,  and 
consequently  reduces  the  period  of  acid  secretion  in  the  stomach.  It 
proves  very  serviceable  in  the  dietetic  treatment  of  gastric  ulcer,  and 
may  be  given  alone  or  combined  with  milk  or  salted  meat  broths  and 
bread  crumbs.  Leube  prescribes  in  this  form  an  equivalent  of  half 
a  pound  of  beef  in  twenty-four  hours,  and  claims  good  success  for  it. 
Mosquera's  beef  jelly  may  be  employed  (p.  133). 

As  a  rule,  if  a  patient  thrive  upon  a  diet  of  milk  and  broths, 
it  is  best  to  let  well  enough  alone  for  two  or  three  weeks,  and  any 
increase  in  either  the  quantity  or  variety  of  the  diet  should  be  made 
with  extreme  caution.  If  improvement  follows,  as  indicated  by  the 
diminution  in  pain  and  the  absence  of  gastric  distress  after  eating, 
and  the  patient  gains  in  strength,  other  articles  may  be  added  in 
moderation  to  the  diet,  such  as  milk  toast,  sweetbread,  eggs  (not 
hard-boiled),  scraped  meat,  custard,  a  small  piece  of  boiled  or  broiled 
white  meat  of  chicken  or  mutton  or  fish,  chicken  broths  thickened 
with  arrowroot,  rice,  vermicelli,  clear  meat  broths  or  thickened  soups 
to  which  the  yolk  of  an  egg  has  been  added,  or  crumbled  dry  toast 
and  a  carefully  prepared  puree  of  potatoes  may  be  prescribed.  Malt 
may  be  added  to  the  puree. 

A  few  easily  digestible  solid  foods  may  next  be  included  in  the 
menu,  such  as  a  tender  rare  roast  beef,  beefsteak,  tender  game,  like  the 
breast  of  partridge,  quail,  or  a  squab  in  season.  The  soft  part  of  large 
oysters  (raw  or  broiled),  boiled  fresh  fish,  such  as  bass,  sole,  or 

whiting,  rice  pudding,  bread  and  milk  pudding,  tapioca,  sago,  farina, 
41 


610  DIET  IN  DISEASES  OF  THE  STOMACH 

and  cornstarch  —  are  all  articles  which  may  be  permitted  in  modera- 
tion. 

The  patient  should  be  informed  of  the  existing  condition  in  the 
stomach,  and  of  the  dangers  attending  any  departure  from  the  rules 
of  diet  prescribed,  and  it  should  be  explained  that  for  several  months 
after  the  acute  symptoms  of  gastric  ulcer  have  subsided  the  greatest 
care  should  be  observed  not  to  overload  or  overwork  the  stomach,  and 
to  refrain  from  eating  food  such  as  coarse  bread  or  groats,  or  vege- 
tables having  tough  outside  covering,  like  peas,  corn,  and  beans,  all 
of  which  are  liable  to  produce  mechanical  irritation  and  possibly  give 
rise  to  hemorrhage.  No  fruit  except  orange,  lemon,  pine  apple  or 
peach  juice  should  be  allowed. 

William  Osier  recommends  the  following  menu  for  gastric  ulcer : 
8  A.  M. —  200  c.  c.  (7  ozs.)  of  Leube's  soluble  meat.  12  noon. — 
300  c.  c.  (10  ozs.)  of  milk  gruel  or  peptonized  milk  gruel  made  with 
ordinary  flour  or  arrowroot,  to  which  an  equal  quantity  of  peptonized 
milk  is  added.  4  p.  M. —  Buttermilk.  8  P.  M. —  Gruel.  In  addition, 
rectal  alimentation  is  to  be  given.  The  whites  of  eight  eggs  may  be 
used  in  alternation  with  the  beef  solution. 

After  a  month  of  this  treatment  the  following  articles  are  cau- 
tiously given:  Scraped  beef,  chicken,  fresh  sweetbread,  a  farina- 
ceous pudding  made  with  milk  and  eggs.  This  treatment  should 
last  three  months,  most  of  which  time  is  to  be  spent  in  bed.  I  have 
rarely  found  it  necessary  to  continue  the  regimen  for  so  long  a 
period. 

The  rules  for  stimulants  are  that  they  should  be  forbidden  abso- 
lutely unless  they  become  necessary  through  exhausting  hemorrhage 
or  great  weakness,  in  which  event  they  had  better  be  supplied  through 
the  rectum. 

Yon  Ziemssen  prescribed  Carlsbad  water  in  order  to  neutralize  the 
acidity  of  the  stomach  and  hurry  its  contents  into  the  duodenum. 
He  recommended  drinking  half  a  pint  to  a  pint  of  this  wafer  hot 
early  in  the  mornings  during  convalescence. 

Aerated  waters  are  not  to  be  recommended.  The  gas  is  likely  to 
distend  the  stomach,  and  the  carbonic  acid  is  believed  to  be  irritating 
to  the  raw  surface  of  the  ulcer. 

S.  W.  Lambert  lately  has  advocated  a  liberal  diet  of  solid  animal 
food  for  gastric  ulcer  on  the  ground  that  ulcers  anywhere  in  the  body 
heal  best  when  nutrition  standards  are  raised.  Naturally  much  de- 
pends upon  the  degree  of  ulceration  and  it  is  hazardous  to  irritate 
large  ulcers  with  solid  food.  (Compare  Coleman's  treatment  of 
typhoid  fever  with  forced  feeding,  page  478.) 


CANCER  OF  THE  STOMACH  611 

CANCER  OF  THE  STOMACH 

In  cancer  of  the  stomach,  prolongation  of  the  patient's  life  and 
personal  comfort  depends  more  upon  the  dietetic  than  any  other 
form  of  treatment.  Nourishment  should  be  given  in  a  concentrated 
and  predigested  form,  and  where  pyloric  obstruction  exists,  in  a  con- 
dition which  admits  of  direct  absorption  from  the  stomach  wall.  It 
is  necessary  to  avoid  food  that  is  liable  to  remain  long  in  the  stomach 
and  excite  nausea  and  vomiting,  which  may  in  turn  develop  severe 
pain  or  fatal  hemorrhage,  and  to  prohibit  anything  which  by  un- 
due fermentation  might  cause  distention. 

In  organic  disease  of  the  stomach,  pain  usually  begins  soon  after 
eating  and  continues  until  its  digestion  is  over  or  vomiting  occurs, 
but  sometimes  the  pain  of  carcinoma  may  be  relieved  by  ingestion  of 
food. 

In  gastric  carcinoma  the  gastric  juice  is  either  deficient  in  quan- 
tity or  altered  in  composition,  and  the  hydrochloric  acid  may  be 
totally  absent.  Hence  stomach  digestion  cannot  be  counted  upon  at 
all,  and  it  is  important  to  digest  all  food  by  artificial  processes.  ^ 

In  nearly  all  cases  nutrient  enemata  will  sooner  or  later  be  re- 
quired either  as  an  adjunct  to  stomach  feeding  or  to  replace  it  en- 
tirely. Owing  to  the  importance  of  this  subject,  it  is  separately 
discussed  on  p.  455.  If  much  pain  follows  the  ingestion  of  any 
food,  or  if  there  is  a  tendency  to  hemorrhage,  stomach  feeding  should 
be  replaced  entirely  in  this  manner.  In  no  other  disease  may  life 
be  supported  for  so  long  a  time  and  so  comfortably  upon  exclusive 
rectal  alimentation.  .  After  a  few  days  of  rest  secured  by  substitu- 
tion of  enemata  the  stomach  may  become  less  intolerant  and  food 
again  may  be  swallowed. 

Patients  soon  find  by  experience  what  gives  them  most  distress 
and  learn  to  avoid  it.  In  general,  saccharine  and  farinaceous  foods 
should  be  proscribed  because  they  normally  are  not  digested  in  the 
stomach,  and  in  carcinoma  they  linger  and,  aided  by  the  catarrh 
which  is  usually  also  present,  undergo  abnormal  fermentation  with 
production  of  gas,  nausea,  and  vomiting.  It  is  commonly  the  case  that 
predigested  albuminous  food  is  better  assimilated,  but  digestion  in 
such  cases  should  be  watched  from  day  to  day,  and  when  patients 
can  tolerate  a  little  simple  farinaceous  food  without  its  producing 
eructations  or  increasing  the  gastric  p'ain  and  discomfort,  it  may  be 
added.  A  solution  of  milk  sugar  may  be  tried. 

If  the  new  growth  causes  stricture  of  the  cardiac  end  of  the  stom- 
ach, only  fluid  food  can  be  taken,  and  the  act  of  swallowing  should 


612  DIET  IN  DISEASES  OF  THE  STOMACH 

be  studied  to  make  sure  that  dilatation  of  the  oesophagus  is  not 
developing.  If,  on  the  other  hand,  it  constricts  the  pyloric  end,  food 
cannot  pass  on  into  the  intestine  and  gastric  dilatation  may  result. 
It  then  becomes  most  important  to  put  into  the  stomach  only  that 
which  can  be  absorbed  from  its  wall.  Such  substances,  besides  water, 
include  peptones,  albumoses,  and  alcoholic  stimulants  (champagne, 
whisky,  and  brandy),  all  which  may  be  taken  up  by  the  circulation 
of  the  gastric  wall  in  considerable  quantity.  Albumoses  theoretically 
constitute  a  most  useful  food,  being  entirely  predigested  and  ready 
for  immediate  absorption ;  but  practically  patients  soon  weary  of  such 
a  diet,  and  food  of  that  nature  will  not  long  support  life  when  given 
alone. 

Exceptionally,  if  the  disease  has  not  progressed  too  far,  patients 
do  best  on  a  dry  diet,  and  finely  chopped  steak,  tender  rare  beef, 
chicken,  scraped  beef,  soft-cooked  or  raw  eggs  may  be  given,  and 
digestion  is  facilitated  by  the  use  of  pepsin  and  hydrochloric  acid  or 
papoid. 

If  there  is  no  pyloric  obstruction,  and  if  the  growth  does  not  produce 
nausea  or  pain,  simple  forms  of  starchy  food  may  be  added,  such  as 
dry  bread,  toast,  or  crackers.  Not  infrequently  delusive  intervals 
of  considerable  improvement  in  digestion  occur,  with  gain  in 
weight. 

Oppolzer  advises  the  use  of  sour  milk  in  cases  of  carcinoma  of 
the  stomach  in  which  there  is  more  or  less  constant  tendency  to  vom- 
iting, and  in  which  ordinary  milk  coagulates  in  the  stomach  in  large 
curds.  Sour  milk  is  much  less  apt  to  form  large  tough  coagulse  (see 
p.  92).  It  is  usually  better,  however,  in  such  cases  to  pancreatinize 
the  milk  or  give  it  in  the  form  of  koumiss. 

For  the  control  of  vomiting  there  also  may  be  tried  iced  carbonic 
water,  champagne,  bismuth,  and  mild  counter-irritation,  with  turpen- 
tine stupes  or  a  mustard  paste. 

It  is  almost  needless  to  say  that  no  such  thing  as  a  dietetic  "  cure  " 
for  cancer  exists.  The  most  that  can  be  expected  of  any  dietetic  treat- 
ment for  this  fatal  disease  is  that  it  may  make  the  patient  somewhat 
more  comfortable,  and  prolong  his  life  perhaps  for  a  few  weeks  or 
months  by  maintaining  better  general  nutrition. 

Lavage  is  sometimes  employed  as  an  adjunct  to  dietetic  treatment 
where  much  catarrh  of  the  stomach  or  dilatation  is  present.  It  may 
relieve  some  of  the  symptoms  in  the  early  stages  of  the  disease,  but 
it  should  lie  performed  with  great  care,  for  it  is  uncertain  to  what 
extent  the  stomach  wall  may  be  eroded  (p.  598)  and  there  is  danger 
of  perforating  it. 


DIAERHCEA  613 

DISEASES  OF  THE  INTESTINES 
DIARRHCEA 

.Pathological  Physiology. —  Diarrhoea  is  commonly  the  result  of 
excessive  peristalsis.  It  also  may  be  occasioned  by  the  presence  of  a 
large  volume  of  fluid  in  the  intestine,  caused  either  by  lack  of  ab- 
sorption of  an  excess  of  liquid  ingested,  or  oftener  by  hypersecre- 
tion  or  failure  to  absorb  the  fluid  of  the  chyme. 
The  exaggerated  peristalsis  is  occasioned  — 

1.  By  increased  irritation  of  the  nerves  or  muscles  of  the  intes- 
tine, due  to  mechanical  stimulation  of  irritant  or  undigested  particles 
of  food  (e.  g.,  the  seeds  of  berries  or  husk  of  corn  grains). 

2.  By  chemical  products  which  are  contained  in  the  food. 

3.  By  abnormal  fermentation,  the  products  of  which  excite  mus- 
cular contractions.     There  are  many  dietetic  causes  of  diarrhoea.     It 
may  be  produced  by  fermented  or  putrefactive  food,  improper  food 
mixtures,   food   which  is  too   coarse,  bulky,   and   irritating,   or   by 
monotony  of   diet.     The  excessive  use  of  meat   extracts   or   "pep- 
tones "  is  liable  to  cause  it.     In  the  tropics,  as  shown  among  the 
troops  employed  in  Cuba  and  Porto  Eico  in  the  Spanish-American 
war,  it  may  originate  from  a  salt-pork  ration,  the  consumption  of  too 
much  meat,  or  canned  dried  beans  ("  baked  beans  ").     In  hot  weather, 
generally,  catarrhal  enteritis  is  easily  developed,  and  animal  food  soon 
spoils  if  exposed  to  the  heat  and  air. 

Diarrhoea  may  be  (a)  acute,  due  to  temporary  errors  in  diet,  "  tak- 
ing cold,"  causing  acute  intestinal  catarrh,  the  ingestion  of  poisons, 
overdoses  of  aperients,  etc.,  or  (&)  chronic,  complicating  some  intes- 
tinal or  other  malady. 

Acute  diarrhoea  often  subsides  of  itself  if  food  be  withheld  until 
the  irritant  matter  has  passed  off  from  the  intestine,  but  chronic 
diarrhoea  of  long  standing  requires  great  care  and  patience  in  treat- 
ment. 

Abundant  greenish  fluid  stools  showing  much  bile  pigment  indi- 
cate that  the  stools  have  been  hurried  out  of  the  small  intestine 
before  digestion  was  complete. 

Of  the  many  forms  of  diarrhoeal  diseases,  the  treatment  of  those 
only  which  are  influenced  most  by  diet  will  be  discussed  in  the  suc- 
ceeding pages.  There  are  a  few  axioms  which  have  general  applica- 
tion to  the  different  varieties,  which  will  be  mentioned  here. 

Dietetic  Treatment. —  It  is  a  general  rule  to  moderate  the  quantity 
of  food  and  avoid  all  food  likely  to  undergo  abnormal  fermentation 


614  DIET  IN  DISEASES  OF   THE  INTESTINES 

(such  as  sugars),  or  having  a  considerable  residue.  TJnirritating  or 
bland  substances  only  should  be  taken,  and  all  fruits  and  vegetables 
are  interdicted. 

At  the  commencement  of  a  sharp  acute  attack  food  may  be  with- 
held for  ten  or  twelve  hours,  and  a  little  barley  water  or  arrowroot 
gruel  flavored  with  a  mere  taste  of  lemon  or  spice  should  then  be  or- 
dered with  a  tablespoonful  of  brandy  in  soda  water.  Mutton  or 
chicken  broth  may  next  be  given,  and,  if  desirable,  it  may  be  thick- 
ened with  boiled  rice,  tapioca,  sago,  or  cracker  crumbs.  Patients  who 
are  not  at  the  same  time  "  bilious  "  or  vomiting  may  take  milk  di- 
luted with  one-third  lime  water. 

The  return  to  ordinary  diet  should  be  gradual  in  all  cases,  and 
such  articles  as  milk  toast,  oysters,  well-cooked  macaroni,  boiled  rice 
with  beefsteak  gravy,  the  breast  of  boiled  chicken,  or  a  sweetbread 
with  baked  or  mashed  potato  may  first  be  allowed. 

Loose  stools  sometimes  appear  immediately  after  meals,  the  im- 
pulse for  the  bowels  to  move  coming  so  suddenly  that  the  patient 
scarcely  has  time  to  leave  the  table  for  the  closet.  This  condition 
is  usually  of  neurotic  origin.  The  patient  should  be  put  upon  a  dry 
diet  restricted  to  meat  and  stale  bread  or  toast  for  a  few  days,  and 
made  to  lie  down  and  rest  immediately  after  meals.  Taking  much 
food  into  the  stomach  excites  a  reflex  intestinal  peristalsis,  and  the 
intestinal  contents  are  hurried  onward  before  they  can  be  digested. 

For  the  form  of  diarrhoea  which  occurs  in  hysterical  women,  if  a 
milk  diet  is  not  well  borne,  the  patient  may  be  fed  upon  egg  albumen 
and  beef  juice  exclusively,  while  medicinal  antispasmodics  are  given 
to  diminish  peristalsis. 

In  diarrhoeas  demulcent  and  mucilaginous  drinks  are  useful,  and 
are  believed  to  coat  the  alimentary  canal  and  protect  it  from  local 
irritation.  It  is  doubtful,  however,  whether  any  such  action  extends 
beyond  the  stomach. 

Diarrhoea  in  Infants  and  Young  Children 
Dietetic  Causes. —  The  dietetic  causes  of  diarrhoea  in  infants  and 
young  children  may  be  classed  as  due  to  —  1.  Too  frequent  or  irreg- 
ular feeding.     2.  Overfeeding.     3.  Improper  or  "  spoiled  "  food. 

The  first  and  second  causes  are  commonest  in  early  infancy,  and 
the  third  in  childhood,  although  any  or  all  of  them  may  operate  at 
any  age. 

Children  brought  up  in  the  country  are  less  subject  to  diarrhceal 
disorders  than  those  raised  among  the  poor  in  cities,  owing  to  the 
relative  purity  of  their  milk  and  other  foods,  and  the  greater  re- 


DIARRHCEA  615 

sisting  power  with  which  their  better  general  health  and  vigor  sup- 
plies them. 

In  a  series  of  nearly  two  thousand  cases  among  infants  of  fatal 
diarrhoea,  collected  by  various  observers  (Hope,  Meinert,  Ballard), 
only  3  per  cent  received  the  breast  exclusively.  These  are  very  sig- 
nificant data,  and  point  to  the  conclusion  that  the  large  majority  of 
cases  are  due  solely  to  the  use  of  improper  or  germ-contaminated  food. 

In  diarrhoea  occurring  in  nursing  infants,  germs  may  have  access 
to  the  child's  mouth  from  an  unclean  nipple  or  from  sucking  its  own 
soiled  fingers.  Aside  from  this,  anything  which  disturbs  the  mother's 
digestion  may  beget  diarrhoea  in  her  baby,  as,  for  example,  improper 
food,  menstruation  or  pregnancy  (rarely),  strong  nervous  influences, 
such  as  grief  or  worry,  great  exhaustion,  extreme  anaemia,  the  use  of 
certain  powerful  drugs. 

Evidently  the  intestine  becomes  stronger  or  less  susceptible  to 
bacterial  poisons  after  the  first  two  years  or  thirty  months  of  life, 
for  the  frequency  of  serious  diarrhoea  lessens,  although  the  child 
often  receives  poorer  milk  to  drink  than  it  had  when  fed  upon  the 
bottle. 

It  has  been  suggested  that  water  may  excite  diarrhoea  by  hurriedly 
washing  germs  into  the  intestine  which  are  ordinarily  killed  in  tran- 
sit by  the  acid  of  the  stomach.  The  bile  is  reputed  to  be  antiseptic, 
but  Booker  has  found  that  many  bacteria  will  grow  in  a  10-per-cent 
solution  of  it,  and  it  easily  undergoes  fermentation  from  decomposi- 
tion of  its  mucus.  Its  antiseptic  reputation  rests  upon  the  fact  that 
it  stimulates  peristalsis,  keeps  the  bowels  moving,  and  thereby  pre- 
vents food  from  accumulating  and  fermenting  abnormally. 

In  large  cities,  where  women  among  the  poor  are  obliged  to  go 
out  to  work  by  the  day,  they,  as  a  rule,  suckle  their  infants  for  only 
the  first  six  months,  or  if  for  a  longer  period,  they  add  other  food  or 
have  their  babies  bottle-fed  by  a  neighbor  or  in  a  "day  nursery" 
during  the  hours  in  which  they  themselves  are  away  from  home. 
Such  hand-fed  children  are  often  given  more  than  they  can  assimilate. 
As  the  infant  grows  older  for  economy  it  is  brought  to  the  family 
table,  and  when  a  year  and  a  half  old  it  is  not  seldom  stuffed  with 
any  articles  from  it.  Beer,  sausages,  bananas,  potatoes,  tea,  and 
coffee  —  all  are  given.  Overfeeding  and  the  use  of  such  harmful  food 
maintains  almost  constant  dyspepsia,  and  if  it  does  not  itself  cause 
diarrhoea  predisposes  to  it  by  keeping  the  alimentary  canal  in  a  con- 
stant state  of  irritation  or  hyperaemia,  so  that  slight  additional  factors 
excite  the  condition,  and  bacteria  find  a  fertile  soil  in  which  to  de- 
velop. 


616  DIET  IN  DISEASES  OF  THE  INTESTINES 

In  older  children  foods  which  are  among  the  producers  of  diarrhoea 
are  unripe  or  overripe  fruits  of  all  kinds,  berries  with  seeds,  vegetables 
having  a  tough  outer  envelope,  such  as  old  peas,  beans,  and  green 
corn,  imperfectly  cooked  cereals,  like  coarse  hominy,  rice  or  oatmeal, 
nuts,  raisins,  citron,  and  dried  currants.  Generally  speaking,  di- 
arrhcea  is  more  likely  to  be  caused  by  unripe  fruits  and  tough  meats 
imperfectly  masticated  than  by  vegetables. 

Examination  of  the  Infant  Stools. —  In  all  serious  cases  the  stools 
should  be  examined,  if  possible,  microscopically,  to  determine  the 
degree  of  digestion  and  absorption  of  the  food.  The  chief  abnormal 
ingredients  are  fat,  bacteria,  mucus,  casein,  starch,  and,  if  meat  has 
been  eaten,  muscle  fibers.  The  green  diarrhoea  of  infancy  is  usually 
of  microbic  origin.  Diarrhoea  of  putrid  character  is  due  to  albu- 
minous fermentation,  and  begets  more  severe  symptoms  (see  Ptomaine 
Poisoning,  p.  419),  than  those  produced  by  the  simple  fetid  stools  of 
starch  fermentation.  (See  Autointoxication,  p.  621.) 

Fat. —  The  normal  percentage  of  fat  which  the  stools  contain  is, 
according  to  Uffelmann's  analysis,  fourteen  on  the  average,  but  in 
diarrhoea  with  intestinal  dyspepsia  it  rises  often  to  forty  or  fifty,  and 
it  has  reached  sixty-four.  The  fat  appears  in  minute  white  flocculi, 
varying  in  size  from  that  of  a  pin's  head  to  a  split  pea.  These  small 
masses  are  often  mistaken  for  casein,  but  the  careful  researches  of 
Wegscheider,  Baginsky,  and  others  have  demonstrated  them  to  be 
composed  of  inspissated  fat  and  colonies  of  bacteria.  It  is  an  easy 
matter  to  distinguish  them  from  casein,  as  they  alone  are  dissolved 
by  the  addition  of  a  few  drops  of  alcohol  and  ether. 

Bacteria. —  The  commonest  bacteria  of  infant  stools  are  the  Bac- 
terium lactis  aerogenes  and  the  Bacterium  coli  commune.  In  fact, 
these  two  normal  varieties  are  the  only  constant  kinds  in  milk-fed 
babies  (Escherich),  although  Booker  has  found  in  different  cases  of 
infantile  diarrhoea,  and  especially  cholera  infantum,  forty  varieties  in 
all,  which  bear  no  special  relation  to  particular  foods.  The  first- 
named  germ  appears  only  when  milk  has  been  ingested,  for  it  thrives, 
as  its  name  indicates,  upon  lactose.  Its  chief  site  is  the  small  intes- 
tine, where  it  causes  milk  to  ferment.  The  Bacterium  coli  commune, 
on  the  contrary,  elects  the  large  intestine  and  thrives  upon  the  residue 
of  digested  food.  Booker  is  of  the  opinion  that  the  influence  of  the 
various  pathogenic  germs  in  the  production  of  diarrhoea  is  attributable 
more  to  alteration  of  the  food  and  intestinal  contents  than  to  direct 
irritation  of  the  intestinal  wall.  The  intestinal  flora  is  of  greater 
variety  in  infants  fed  on  cow's  milk  than  in  those  fed  at  the  breast. 

Casein. —  Undigested  casein  is  a  less  common  ingredient  of  the 


DIAERHCEA  617 

stools  than  was  supposed  before  the  above-described  observations  were 
made.  When  present  it  is  in  the  form  of  smooth,  somewhat  hard 
masses,  often  of  a  yellow  or  yellowish-white  color  without,  but  white 
when  broken  open.  They  are  usually  friable,  and  have  a  cheesy  odor. 
They  may  present  a  semi-transparent  appearance. 

Starch. —  Starch  granules  appear  in  the  stools  very  often  when  im- 
perfectly cooked  amylaceous  food  has  been  eaten,  such  as  oatmeal, 
barley,  potatoes,  bread,  etc.  They  are  recognized  by  the  microscope, 
and  by  the  addition  of  a  solution  of  iodine,  which  colors  the  stools  dark 
blue. 

Meat  Fiber. —  Muscle  fibers  are  easily  recognizable  by  microscopic 
examination,  but  not  otherwise. 

Dietetic  Treatment. —  The  principles  of  dietetic  treatment  of  sim- 
ple bacteria  or  mycotic  diarrhoea  occurring  in  infants  under  two  years 
of  age  are  to  let  the  alimentary  canal  rest,  and  later  to  give  food 
which  is  very  thoroughly  absorbed,  leaving  the  least  possible  residuum 
of  waste.  All  food  is  to  be  withheld  for  a  few  hours,  and  cool  ster- 
ilized water  or  barley  water,  and  cracked  ice  (if  pure)  is  given  to  allay 
thirst.  The  child  will  not  suffer  from  lack  of  food,  but  will  suffer 
much  more  with  it. 

After  the  interval  of  rest  food  is  to  be  cautiously  administered, 
but  in  less  than  the  usual  quantity.  Unless  the  infant  can  have 
breast  milk,  which  is  usually  most  desirable  for  it,  it  is  best  to  give 
no  milk  at  all,  but  instead  such  articles  as  whey,  thin  mutton  or 
chicken  broth,  barley  gruel,  or  egg  albumen  beaten  in  half  a  pint  of 
cold  water  to  which  a  teaspoonful  of  brandy  and  a  pinch  of  salt  are 
added.  After  two  or  three  days  of  this  diet,  if  the  child  continues 
to  improve,  the  milk  diet  given  before  the  illness  is  to  be  resumed 
gradually,  but  the  feeding  should  be  watched  for  at  least  a  week. 

To  older  children,  when  diarrhoea  has  been  excited  by  eating  im- 
proper food,  unless  the  bowels  have  been  evacuated  already  very 
thoroughly,  or  if  signs  of  intestinal  irritation  continue,  it  is  best,  as 
with  adults,  to  give  castor  oil  and  opium  in  the  form  of  paregoric  or 
Dover's  powder,  and  then  to  feed  the  child  upon  the  principles  laid 
down  above  for  infants.  As  a  rule,  it  is  desirable  to  avoid  "  pre- 
pared foods  "  or  patented  infant  foods,  and  good  nutritious  home- 
made fresh  broth  from  lean  mutton,  or  chicken,  or  beef,  is  to  be  pre- 
ferred. 

Enterocolitis  in  Infants  and  Children  —  Summer  Diarrhoea 

Summer  diarrhoaa  is  exceedingly  fatal  among  infants  in  hot  weather 
in  densely  populated  localities,  and  they  require  very  careful  feeding 
in  this  disease.  Intractable  cases  are  prolonged  for  several  weeks,  with 
42 


618  DIET  IN  DISEASES  OF   THE  INTESTINES 

more  or  less  vomiting,  diarrhceal  mucous  stools,  fever,  and  meteorism, 
and  marasmus  and  a  variety  of  complications  supervene. 

Prevention. —  Enterocolitis  is  a  subacute  milk  infection,  resembling 
the  acute  form,  cholera  infantum,  but  is  less  violent,  although  much 
more  prevalent.  It  is  produced  by  toxins  developed  by  the  activity  of 
bacteria  in  the  food,  and  it  is  therefore  preventable,  and  most  easily  so 
by  exclusive  breast  nursing. 

The  preventive  treatment  for  weanlings  in  nurseries  where  there 
are  several  children  consists  in  absolute  cleanliness  and  antisepsis, 
and  the  nurse  must  be  made  to  realize  the  necessity  of  disinfecting 
diapers  and  her  own  hands  at  once,  and  she  must  never  handle  either 
food  or  food  utensils  with  soiled  hands,  for  by  neglect  of  these 
simple  precautions  the  germs  are  passed  on  from  one  child  to 
another.  When  cow's  milk  is  used  in  hot  weather  it  should  be  pas- 
teurized. 

Dietetic  Treatment. —  As  a  preliminary  to  dietetic  treatment  the 
alimentary  canal  should  be  evacuated  of  all  irritant  material.  The 
stomach  should  be  washed  out  through  a  funnel,  a  (Xo.  10)  soft 
rubber  catheter,  hot  water  (102°  F.)  being  used,  to  which  salt  is 
added  (a  teaspoonful  to  the  quart).  The  colon  should  be  similarly 
irrigated  with  hot  salt  solution.  If  the  child  is  still  nursing,  and  the 
mother's  milk  is  found  to  disagree,  a  wet  nurse  should  be  secured 
whenever  possible.  If  the  child  is  fairly  strong  and  well  nourished 
at  the  commencement,  it  is  preferable  to  withhold  all  food  for  several 
hours,  and  merely  give  a  little  barley  water  or  some  equally  bland 
beverage.  In  any  event  it  is  best  to  abandon  milk  and  its  prepara- 
tions entirely  for  two  or  three  days.  In  this  manner  the  intestinal 
germs  which  are  causing  the  mischief  are  starved  out  or  replaced  by 
others  which  are  comparatively  innocuous.  There  are  many  cases  of 
enteritis  in  children  in  which  milk  absolutely  disagrees,  even  when 
pasteurized  and  pancreatinized,  apparently  because  the  casein  is  not 
properly  digested  in  the  stomach,  and  it  should  be  prevented  from 
passing  through  the  alimentary  canal  in  tough  and  irritating  coagulae. 

Fresh  meat  broths  (beef,  mutton,  or  veal),  pressed  meat  juice,  and 
egg  albumen  solution  are  to  be  given  in  lieu  of  milk.  Children  a  year 
or  more  old  may  have  gruels  of  arrowroot,  barley,  or  rice,  but  com- 
mercial "  baby  foods  "  and  patented  meat  extracts  should  be  avoided. 
A  mixture  of  cream  and  water  is  sometimes  well  borne. 

It  is  important  to  furnish  nourishment  in  very  moderate  quantity, 
one  or  two  teaspoonfuls  at  a  time,  to  prevent  overfilling  of  the  stom- 
ach. For  older  children  a  little  scraped  beef  may  be  prescribed  three 
times  a  day  :  and  they  may  be  allowed  to  drink  whey. 


CHOLERA  INFANTUM  619 

After  several  days,  but  not  until  the  acute  symptoms  have  disap- 
peared, a  very  gradual  return  to  milk  is  permissible. 

In  those  cases  in  which  children  lose  all  appetite  or  infants  persist- 
ently refuse  to  take  the  bottle,  the  prognosis  is  extremely  unfavorable, 
and  recourse  should  be  had  to  rectal  feeding  and  stimulation.  In  every 
protracted  case  an  exact  record  should  be  kept  of  the  quantity  of  food 
taken,  and  no  general  report  accepted  from  the  nurse  that  the  child 
is  simply  "feeding  well."  Frequent  weighing  and  comparison  with 
the  amount  of  food  ingested,  combined  with  personal  observation  of 
the  stools,  are  the  best  guides  and  should  never  be  neglected. 
.  During  convalescence  older  children  should  be  watched  to  see  that 
they  do  not  surreptitiously,  or  through  ignorance  of  their  nurses, 
obtain  unwholesome  food.  Such  articles  as  potatoes,  tomatoes,  and 
other  fresh  vegetables,  coarse  cereals  like  oatmeal,  wheaten  grits,  and 
cornmeal,  are  forbidden,  as  well  as  fruits.  Holt  has  seen  a  fatal 
result  from  eating  a  few  raisins. 

CHOLERA  INFANTUM,  OR  ACUTE  MILK  INFECTION 

Cholera  infantum  is  a  gastro-intestinal  disease  of  violent  acuteness, 
characterized  by  severe  vomiting,  purging  by  serous  stools,  collapse, 
very  rapid  emaciation,  thirst,  fever,  and  other  symptoms.  According 
to  Holt,  between  2  and  3  per  cent  of  the  cases  of  diarrhoeal  disease  in 
infants  are  cholera  infantum. 

It  does  not  occur  in  nursing  infants,  but  only  in  those  fed  by  arti- 
ficial means.  No  specific  microorganism  has  been  detected,  although 
various  germs  abound  in  the  watery  evacuations.  Vaughan  believes  it 
to  be  due  to  tyrotoxicon,  which  he  has  demonstrated  in  cow's  milk 
(p.  424),  and  which  exists  only  in  milk  or  some  modified  form  of  it, 
such  as  condensed  milk,  or  baby  food  made  in  part  of  milk.  The  dis- 
ease prevails  especially  in  hot  weather,  and  is  so  rapidly  fatal,  usually 
within  one  or  two  days,  that  prompt  and  vigorous  action  is  imperative. 

Dietetic  Treatment. —  The  giving  of  milk  in  any  form  should  imme- 
diately and  peremptorily  be  stopped,  and,  as  Vaughan  says :  "  Pre- 
pared baby  foods  should  be  thrown  out  of  the  window.  Acute  milk 
infection  is  a  form  of  poisoning  by  a  substance  more  powerful  and 
deadly  than  white  arsenic."  The  poison  must  therefore  be  washed 
out;  and  no  matter  how  much  vomiting  and  diarrhoaa  have  already 
occurred,  the  stomach  must  be  cleansed  by  lavage,  and  the  colon  irri- 
gated by  at  least  a  gallon  of  warm  Castile  soapsuds  and  water,  after 
which  cool  water  with  fifteen  to  thirty  grains  of  tannic  acid  to  the  pint 
should  be  injected  (Vaughan),  with  the  object  of  precipitating  pois- 


620  DIET  IN  DISEASES  OF  THE  INTESTINES 

onous  proteids.  The  irrigation  has  a  further  advantage  in  that  it 
replenishes  by  absorption  a  portion  of  the  water  which  has  been 
drained  rapidly  from  the  system  by  the  violent  purging,  as  in  the  case 
of  Asiatic  cholera,  and  the  loss  of  which  causes  insatiable  thirst.  The 
lavage  allays  gastric  irritability,  and  alcoholic  stimulation  then  should 
be  ordered  in  the  form  either  of  half  a  teaspoonful  of  iced  champagne 
or  from  ten  or  fifteen  drops  to  a  teaspoonful  of  whisky  or  good  brandy, 
diluted  in  water  or  Vichy.  From  three  to  four  ounces  may  be  given 
in  twenty-four  hours  to  avert  collapse.  If  necessary,  the  brandy  is  to 
be  given  by  rectum,  or  the  whisky,  in  urgent  cases,  by  hypodermic 
injection.  . 

Accessory  means  are  bathing  in  warm  mustard  water  and  friction. 
No  nourishment  except  the  alcohol  is  allowable  for  at  least  twenty- 
four  hours,  when  warm  meat  juice,  pancreatinized  meat  broths,  or  egg 
albumen  is  to  be  prescribed  in  teaspoonful  doses  every  half  hour  or 
hour.  For  a  day  or  two  this  diet  will  suffice,  and  milk  should  not  be 
given  again  in  any  form  until  the  expiration  of  that  time,  when  the 
ordinary  previous  diet  may  be  cautiously  resumed.  Older  children 
may  be  allowed  to  have  scraped  beef  which  has  been  squeezed  through  a 
sieve. 

CHOLERA  MORBUS  — ACUTE  CATARRHAL  ENTE- 
RITIS IN  ADULTS       . 

Cholera  morbus  may  be  caused  by  the  ingestion  of  indigestible  foods 
or  improper  drink,  such  as  polluted  water,  or  water  or  beer  drunk  in 
large  quantity  after  long-continued  thirst,  or  chilling  after  excessive 
exercise  and  perspiration.  An  attack  may  be  excited  by  unripe  fruit 
and  vegetables,  such  as  green  apples,  watermelons,  cucumbers,  or  nuts. 
Other  factors  are  a  hot,  humid  depressing  atmosphere,  chill  after  exces- 
sive perspiration  and  fatigue. 

Dietetic  Treatment. —  The  patient  should  be  kept  quiet  in  bed,  well 
covered,  and  in  severe  cases  it  may  be  advisable  to  give  no  food  for 
the  first  twenty-four  hours,  after  which  the  diet  should  be  very  light, 
consisting  of  meat  broth  or  of  pancreatinized  milk  with  lime  water  in 
proportion  of  one-third  of  the  latter,  given  alone  or  with  a  little  boiled 
rice  or  milk  toast.  Brandy  and  soda  or  champagne  may  be  prescribed. 
The  desire  to  drink  water  constantly  should  be  restrained,  as  it  tends 
to  keep  the  contents  of  the  intestine  too  fluid  and  increases  the  diar- 
rhoea. Thirst  may  be  relieved  by  cracked  ice,  very  weak  cold  tea  with- 
out sugar,  or  a  little  oatmeal  water.  When  the  patient  is  first  seen, 
if  there  is  evidence  of  accumulation  of  irritating  food  in  the  intestine 


AUTOINTOXICATION  621 

which  has  not  been  eliminated  by  the  diarrhoea,  it  is  advisable  to  evac- 
uate the  bowel  with  a  dose  of  castor  oil  or  salts. 

The  following  day,  if  diarrhoea  and  vomiting  have  ceased,  the  diet 
may  be  increased  slowly;  otherwise  it  still  should  be  restricted  to 
broths  and  milk.  Among  the  foods  which  first  may  be  allowed  are 
a  soft-cooked  egg,  raw  oysters,  scraped  beef  with  soda  crackers  or 
toast,  and  well-boiled  rice.  If  the  attack  has  lasted  only  a  day  or 
two,  the  patient  may  soon  return  to  his  normal  diet;  but  if  it  has 
been  protracted,  or  if  he  has  been  much  weakened  by  it,  he  should 
observe  caution  in  eating  for  several  days.  The  diet  for  convalescence 
given  on  p.  472  then  may  be  followed. 

INTESTINAL  FERMENTATION  AND  PUTREFACTION, 
AUTOINTOXICATION 

Intestinal  autointoxication  is  a  toxemia  resulting  from  absorption 
of  abnormal  food  products  formed  within  the  alimentary  canal  by 
bacterial  action.  This  definition  excludes  ptomaine  poisoning,  milk, 
fish,  and  meat  poisoning,  etc. —  conditions  due  to  ingestion  of  sub- 
stances already  poisoned  before  ingestion.  Autotoxsmia  disturbs  the 
vascular,  nervous,  digestive,  and  eliminative  functions,  and  the  toxins 
may  be  demonstrated  in  the  stomach  contents,  feces,  and  urine.  The 
symptoms,  which  have  been  the  subject  of  a  classical  study  by  Prof. 
Christian  H.  Herter,  of  New  York  are  due  to:  1,  fermentation;  2, 
putrefaction. 

1.  Fermentation  symptoms  are  caused  by  the  fermentation  prod- 
ucts of  carbohydrate  food,  principally  C02  and  organic  acids,  such  as 
lactic,  acetic,  and  butyric  chiefly,  and  to  some  extent  formic,  succinic, 
valerianic,  propionic  acids,  and  acetone.  Alcoholic  fermentation  is 
also  present.  These  symptoms  are  in  part  mechanical,  due  to  pres- 
sure from  gas;  such  are:  eructations,  stomach  and  intestinal  tym- 
panites, palpitation,  flatus,  abdominal  tenderness,  and  irregular  stools. 
In  addition  there  may  be  nausea,  vomiting,  a  foul  odor  in  the  breath 
and  feces.  With  the  exception  of  oxalic  acid  in  oxaluria,  fermentation 
products  are  not  recovered  from  the  urine  to  any  extent,  as  the  ulti- 
mate products  of  carbohydrate  food  are  C02  and  water.  Slight  fever 
may  be  present. 

The  severity  of  fermentation  autointoxication  symptoms  depends 
upon:  (1)  the  composition  of  foods,  (2)  the  variety  of  foods,  (3) 
the  number  and  kind  of  bacilli  introduced  with  the  food,  (4)  the 
reaction  and  quantity  of  the  gastric  juice,  (5)  the  motility  of  the 
stomach,  and  (6)  the  rate  of  absorption  of  fermentation  products. 


622  DIET   IN   DISEASES   OF   THE   INTESTINES 

2.  Putrefaction  symptoms  are  caused  by  intestinal  putrefactive 
processes  involving  the  proteid  foods,  and  resulting  in  the  forma- 
tion of  nitrogen  and  sulphur  compounds,  chiefly  of  the  aromatic  series ; 
such  are:  indol,  cresol,  phenol,  skatol,  with  hydrogen  sulphide  gas  as 
a  by-product,  free  nitrogen  and  hydrogen.  Other  less  important  prod- 
ucts are:  putrescin,  cadaverin,  neurin,  leucin,  cystin,  methyl  mercap- 
tan,  and  carburetted  hydrogen.  Excess  of  H2S  produces  hydro- 
thionanaemia.  The  putrefactive  bacillary  processes  take  place  mainly 
in  the  colon,  but  may  extend  to  the  small  intestine  and  stomach.  In 
general  the  symptoms  of  putrefaction  are  more  distinctly  toxic  and 
less  mechanical  (less  gas  is  formed)  than  those  of  fermentation.  The 
effects  of  putrefaction  are  especially  manifest  upon  the  blood  and  nerv- 
ous system. 

Indol  is  derived  from  the  tyrosin  of  proteid  food,  through  action  of 
the  colon  bacillus,  but  it  is  not  derived  in  any  quantity  from  milk.  It 
is  closely  related  to  indican  formation. 

Herter  gave  indol  experimentally  to  several  persons,  with  the  effect 
of  producing  such  symptoms  as  frontal  headache,  vertigo,  restlessness, 
insomnia,  frequent  micturition,  diarrhoea,  and  finally  a  condition  of 
neurasthenia. 

Neurin  is  another  highly  toxic  intestinal  product  formed  some- 
times in  cases  of  intestinal  obstruction,  and  derived  from  lecithin  in 
egg  yolk  and  from  other  sources.  According  to  Herter,  in  man  it 
causes  increased  peristalsis,  diarrhoea,  abdominal  cramps,  and  lessened 
heart  force  and  pulse  tension. 

Whereas  the  nitrogen  and  sulphur  of  putrefactive  products  are 
eliminated  through  the  kidneys  as  ethereal  sulphates,  etc.,  unlike  the 
carbohydrate  final  products,  it  becomes  comparatively  easy  to  detect 
them  and  trace  their  relationship  to  special  articles  of  diet. 

The  clinical  results  of  intestinal  autointoxication  may  be  imme- 
diate or  acute  and  violent,  with  much  gastrointestinal  disturbance,  or 
they  may  be  remote,  i.  e.,  chronic.  In  the  latter  instance  such  condi- 
tions are  associated  as  neuritis,  neuralgias,  tetany,  epilepsy,  anaemia, 
arteriosclerosis,  skin  eruptions  like  eczema,  acne,  pruritus,  and  exfolia- 
tive  dermatitis,  tetany,  poliomyositis,  psychoses,  melancholia  and  neu- 
rasthenia, and  miscellaneous  toxaemias  like  goutiness  and  lithaemia. 
It  is  not  claimed,  of  course,  that  intestinal  autointoxication  is  the  sole 
cause  of  all  these  conditions,  but  it  is  usually  associated  with  them, 
often  antedates  them  or  intensifies  them,  and  they  are  clinically  capable 
of  marked  improvement  under  dietetic  regulation. 

It  should  be  observed  that  in  many  cases  of  intestinal  autointoxica- 
tion the  primary  digestive  disorder  may  be  in  the  stomach.  Hastily 


ATJTOIXTOXICATION  623 

eaten  food,  coarse  or  fermenting  food  which  is  imperfectly  digested  in 
the  stomach,  passes  into  the  intestine  in  a  condition  which  may  give 
rise  to  much  irritation,  and  if  many  bacteria  are  present,  to  the  devel- 
opment of  a  variety  of  more  or  less  toxic  products.  Similarly,  hyper- 
acidity, and  especially  hypermotility  of  the  stomach,  which  causes  the 
food  to  pass  too  quickly  into  the  intestine,  may  favor  intestinal  auto- 
intoxication. 

The  foul  breath  which  characterizes  this  condition  is  in  part 
due  to  the  elimination  through  the  lungs  of  hydrogen  sulphide  gas, 
which,  after  absorption  by  the  intestinal  vessels,  is  conveyed  to  the 
pulmonary  circulation  and  liberated  with  the  exhaled  air. 

Many  chronic  cases  are  rebellious  to  treatment,  for  it  is  more  diffi- 
cult to  control  intestinal  than  gastric  digestion,  not  only  because  the 
intestine  is  relatively  inaccessible,  but  because  of  the  highly  complex 
digestive  processes  in  which  the  bile,  pancreatic  and  intestinal  juices 
are  concerned. 

The  dietetic  treatment  of  autointoxication  is  suggested  by  a-  knowl- 
edge of  its  etiology.  The  fermentation  cases  do  best  upon  a  diet  of 
simple  proteid  foods,  broths,  fish,  chicken,  eggs,  scraped  beef,  etc., 
with  dry  toast,  stale  bread  or  crackers,  i.  e.,  with  a  diet  chiefly  proteid. 
The  putrefactive  cases,  if  severe,  may  be  treated  with  a  diet  of  bread 
and  milk,  later  with  fruits,  cereals,  and  the  fresh  green  vegetables. 
In  both  classes  of  cases  elimination  first  should  be  promoted  by  laxa- 
tives, such  as  calomel  or  castor  oil,  and  the  drinking  of  water  in  large 
quantity ;  in  both,  intestinal  antifermentative  remedies  are  useful,  such 
as  creosote,  B-naphthol,  salol,  ichthyol,  or  bismuth  subgallate. 

Those  mixed  cases  in  which  the  symptoms  of  fermentation  and 
putrefaction  are  combined,  are  treated  best  with  a  temporary  diet  of 
milk  and  bread  or  crackers,  together  with  eliminatives  and  anti-fer- 
mentatives,  as  above  described.  Intestinal  lavage  with  hot  normal 
salt  solution  (a  drachm  to  the  pint)  is  most  helpful.  It  is  in  cases  of 
autointoxication  that  the  sour  milk  treatment  devised  by  Metchnikoff 
of  Paris  produces  oftentimes  exceedingly  favorable  results.  It  is  fully 
described  under  "  Lactobaccilline  "  on  page  92.  Not  all  cases  yield 
to  it,  but  I  have  found  that  very  intractable  ones  often  do,  which  other 
remedies  have  failed  to  relieve. 

SUMMARY  OF  DIET  FOB  INTESTINAL  AUTOINTOXICATION 

I.  Fermentation  Cases 

Fish,  etc. :  Oysters,  stewed  or  broiled,  bass,  bluefish,  fresh  cod,  hali- 
but, redsnapper,  whitefish,  weakfish,  smelts,  boiled  or  broiled. 

Cereals:     Dry  toast,  Graham  bread,  trisket,  hominy   (with  lemon 


624  DIET   IN  DISEASES  OF  THE  INTESTINES 

or  skimmed  milk,  instead  of  sugar  and  cream),  macaroni  without 
cheese. 

Butter  in  small  amount. 

Vegetables:  String  beans,  unsweetened  tomatoes,  stewed  celery, 
stewed  radishes,  spinach,  oyster  plant,  squash,  lettuce,  asparagus,  arti- 
chokes, beet  tops,  endive,  cress,  okra. 

Meats:  Eare  roast  beef,  tenderloin  steak,  mutton  or  lamb  chop, 
roast  mutton  or  veal,  chicken,  capon,  turkey,  guinea  hen,  squab,  par- 
tridge (without  "stuffing"  or  sauces  or  gravies).  Ham,  thin  crisp 
bacon,  tongue,  sweetbread. 

Desserts:  Stewed  fruit,  wine  jelly  or  blancmange  sweetened  with 
saccharine,  custards. 

Fruits:  Oranges,  lemons,  olives,  pineapple  juice,  prunes,  peaches, 
pears,  plums,  apples  in  any  form. 

Beverages:  Tea  or  coffee  without  cream  and  with  saccharine  in- 
stead of  sugar.  Buttermilk. 

77.  Putrefaction  Cases 

Vegetable  soups  or  purees. 

Vegetables:  Potatoes,  peas,  beets,  corn,  parsnips,  tomatoes,  string, 
Lima  and  butter  beans,  spinach,  eggplant,  peppers,  squash,  celery, 
asparagus,  lettuce,  stewed  radishes. 

Bacon,  SAveetbread. 

Fish  once  or  twice  a  week,  such  as  shredded  cod,  fresh  smelts,  red- 
snapper,  weakfish,  whiting,  sole,  flounder,  sunfish,  bass,  trout,  broiled 
or  boiled. 

Butter,  not  more  than  %  oz.  a  day. 

Cereals:  Shredded  wheat,  trisket,  zwieback,  boiled  rice,  puffed  rice, 
hominy,  cornmeal,  wheaten  grits,  rolled  oats,  oatmeal,  Graham  and 
wheaten  bread,  gingerbread,  gingersnaps,  sago,  tapioca,  samp,  macaroni 
and  spaghetti  without  cheese. 

Desserts:  Stewed  fruits,  bread  or  rice  pudding,  dry  spongecake 
and  sherry. 

Fruits:     Fresh  fruit  of  all  kinds. 

Beverages:     Tea,  coffee,  cocoa,  buttermilk. 

7/7.  Mixed  Fermentation  and  Putrefaction  Cases 

Vegetable  soups. 

Cereals:  A  little  stale  bread  or  toast,  Huntley  and  Palmer  wafers, 
toasted  soda  crackers. 

Meats:  Crisp  bacon,  lean  ham,  sweetbread,  broiled  chicken  (once 
or  twice  a  week). 


CHRONIC  ENTERITIS  IN   ADULTS  625 

Fish:  Fresh  fish  (once  or  twice  a  week),  smelts,  whiting,  weak- 
fish,  butterfish,  sole,  flounder,  whitefish. 

Vegetables:  Spinach,  lettuce,  stewed  celery,  tomatoes,  oyster  plant, 
string  beans. 

Butter,  not  more  than  y2  oz.  a  day. 

Beverages:  Weak  tea  with  lemon,  or  coffee  both  without  cream  and 
with  saccharine  in  lieu  of  sugar.  Buttermilk.  Postum. 

IV.  Foods  Forbidden  in  All   Cases 

Pickles,  sauces,  gravies,  condiments,  spices,  preserves,  marmalade, 
jams,  sirup,  cake,  "  cakes,"  pies,  puddings,  pastry  of  all  sorts,  hashes, 
stews,  ragouts,  twice-cooked  and  made-over  dishes  of  every  kind,  veal, 
pork  sausage,  pate  de  foie  gras,  corn  beef,  dried,  smoked,  salted,  canned 
foods  of  every  sort,  new  bread,  hot  rolls,  candy  and  confectionery, 
mushrooms,  lobster,  crabs,  shrimps,  terrapin,  clams,  caviare,  chowder, 
raw  radishes,  cucumbers,  horse-radish,  cranberries,  turnips,  onions, 
cabbage,  cauliflower,  Brussels  sprouts,  eggs,  nuts,  raisins,  berries,  sar- 
dines, salmon,  mackerel,  bluefish. 

CHRONIC  ENTERITIS  IN  ADULTS  —  CHRONIC  INTES- 
TINAL CATARRH  — CHRONIC  COLITIS 

In  severe  cases  it  may  be  advisable  to  order  the  patient  a  milk  diet 
for  several  weeks.  Except  in  tuberculous  subjects  this  is  often  suc- 
cessful in  effecting  a  cure.  The  milk  may  be  skimmed  or  boiled  and 
diluted  with  lime  water.  As  a  rule,  fatty  and  saccharine  food  is  for- 
bidden, and  farinaceous  food  should  be  restricted  in  quantity.  At  first 
fats  fail  of  digestion  in  the  intestine,  and  later  other  foods.  Patients 
should  be  instructed  to  take  their  meals  very  slowly  and  masticate 
sufficiently.  The  diet  should  consist  chiefly  of  bread  and  lean 
meats  —  foods  which  leave  the  least  residue.  Scraped  beef,  beef 
meal,  and  beef  peptonoids  are  useful.  The  intestinal  indigestion  may 
be  improved  by  pancreatic  extracts  with  bicarbonate  of  sodium.  The 
food  may  be  pancreatinized  before  it  is  eaten,  or  pancreatin  may  be 
given  in  keratin-coated  pills  designed  to  remain  undissolved  until  they 
have  reached  the  small  intestine.  The  stools  should  be  watched  for 
undigested  particles  of  food,  muscle  fibers,  etc.  Lactobacilline  should 
be  given  (p.  92). 

If  emaciation  continues  with  an  exclusive  diet  of  animal  food,  it 
may  be  best  to  give  hominy  or  cornmeal  mush  which  is  predigested  with 
diastase  or  malt  extract.  Baked  potatoes  may  be  similarly  treated. 

Foods  to  be  avoided  are  very  rich  milk,  cream,  green  vegetables,  raw 
acid  fruits,  dried  fruits  and  nuts,  richly  cooked  acid  or  fat  dishes, 


626  DIET   IN   DISEASES  OF   THE  INTESTINES 

crustaceans,  pork,  veal,  coarse  bread,  pastry,  sweets,  and  desserts  of 
all  kinds. 

In  milder  cases  in  which  there  is  more  or  less  constipation  with 
intestinal  catarrh,  it  is  important  to  regulate  the  bowels,  and  this 
may  be  done  in  part  by  the  character  of  the  food,  also  by  systematic 
exercise,  both  active  and  passive.  Mild  calisthenics,  massage  of  the 
limbs  and  the  abdominal  wall,  combined  with  abundant  fresh  air,  daily 
bathing  in  cold  water,  and  friction  of  the  skin,  are  all  useful  aids  to 
treatment. 

There  are  cases  of  chronic  colitis  in  adults  which  do  not  improve 
upon  any  special  diet,  and  after  trying  a  great  variety  of  foods  the 
patients  seem  to  progress  better  for  a  time  on  a  mixed  diet  of  con- 
siderable diversity.  In  such  cases  the  lesion  is  in  the  lower  part  of 
the  colon,  so  that  intestinal  digestion  is  fairly  completed  above.  This 
type  of  case  is  particularly  benefited  by  antiseptic  and  mildly  astringent 
intestinal  irrigations. 

Some  patients  are  benefited  by  treatment  for  a  few  weeks  at  one  of 
the  alkaline  mineral  springs. 

An  intestinal  diet  has  been  devised  by  Schmidt  and  Strassburger 
to  aid  in  estimating  the  degree  of  peristalsis  and  other  intestinal 
conditions  which  are  determined  through  examination  of  the  stools. 
The  diet  comprises  milk,  eggs,  mashed  potato,  scraped  meat,  butter, 
oatmeal,  bouillon,  and  zwieback.  If  charcoal  or  carmin  be  added,  these 
substances,  being  insoluble,  reappear  in  the  stools,  thus  marking  off 
the  beginning  and  ending  of  those  stools  which  contain  the  waste  of 
the  test  meals.  (See  p.  401.)  Thus  from  the  time  the  carmin  meal 
is  eaten,  until  the  first  carmin  stool  appears  is  usually  fifteen  to  twen- 
ty-five hours,  but  with  colitis,  especially  in  the  lower  colon,  the  time 
may  be  shortened  to  ten  hours  or  less.  By  varying  the  ingredients  of 
the  test  meals,  one  ingredient  at  a  time,  the  toleration  for  different 
types  of  food,  fats  (butter),  carbohydrates,  meat,  etc.,  is  ascertained. 

CHRONIC  INTESTINAL  INDIGESTION  IN  CHILDREN 

Chronic  intestinal  indigestion  in  children  should  be  treated  by 
dieting  rather  than  by  medicines.  Diligent  inquiry  should  be  made 
into  the  cause  of  the  trouble,  and  the  diet  regulated  accordingly.  The 
stools  and  the  urine  should  always  be  examined.  If  the  former  are 
hard,  white,  and  lumpy,  if  they  are  too  loose  and  contain  undigested 
coagulsp  of  casein  and  drops  of  fat,  or  if  they  are  sour  from  lactic- 
acid  fermentation,  the  milk  is  certainly  disagreeing.  If  the  child 
is  nursing,  the  mother's  milk  may  be  at  fault.  If  the  woman  is 


CHRONIC   GASTROINTESTINAL  CATARRH  627 

worried,  exhausted,  or  possibly  pregnant,  or  suffering  from  insomnia, 
menstrual  disorder,  phthisis,  or  other  chronic  ailment,  or  if  lactation 
is  too  long  continued,  her  milk  may  be  replaced  by  that  of  a  good  wet 
nurse,  or,  failing  this,  by  the  bottle.  This  change  will  often  cure  the 
indigestion  at  once.  It  may  be  that  the  infant  is  simply  overfed,  or 
fed  too  often.  The  excess  of  milk  fails  to  be  absorbed,  undergoes 
lactic-acid  fermentation,  produces  gas  with  abdominal  distention  and 
diarrhoea  or  irregular  passages,  together  with  loss  of  weight,  fretful- 
ness,  and  other  symptoms.  If  the  child  is  being  fed  upon  a  mixed  diet 
with  milk  and  one  of  the  prepared  infant  foods,  such  as  Mellin's, 
Ridge's,  Horlick's,  etc.,  the  difficulty  may  be  with  either  the  proteid 
or  the  carbohydrate  elements,  but  the  prepared  foods  had  better  be 
abandoned.  It  is  easy  to  ascertain  which  is  at  fault  by  confining  the 
diet  exclusively  for  a  few  days  to  one  or  the  other  of  these  classes  of 
foods,  and  noting  the  effect  on  the  bowels.  Moreover,  proteid  in- 
testinal indigestion  usually  produces  offensive  alkaline  feculent  stools, 
while  carbohydrate  indigestion  causes  acid  stools  with  more  flatus. 
Of  course  both  classes  of  indigestion  may  coexist  in  the  intestine,  but 
the  difficulty  is  primarily  with  one  sort  or  the  other,  and  hence  the 
advantage  of  substituting  for  the  mixed  diet  a  more  elementary  one. 
In  place  of  milk,  egg  albumen,  pressed-beef  juice,  and  meat  broths  are 
to  be  given.  Or  if  these  proteids  are  not  digested,  the  diet  should  con- 
sist for  a  few  days  of  barley  or  rice  gruel,  or  gruels  of  "torrefied 
starch  " —  i.  e.,  wheat  flour  which  has  been  boiled  or  roasted  in  order 
to  burst  the  starch  granules  and  partially  convert  the  granulose  into 
dextrin ;  the  predigestion  is  carried  still  further  by  the  use  of  diastase 
or  malt  extract. 

A  mixture  of  cream  and  water  (p.  109)  is  well  tolerated  in  some 
cases,  or  peptonized  milk  and  various  other  preparations  of  milk  may 
be  given;  but  at  present  peptonized  milk  is  less  in  vogue  than  formerly, 
as  its  power  of  restoring  emaciated  tissues  has  been  seriously  called  in 
question.  "  Modified "  or  "  humanized "  milk  is  to  be  preferred 
(p.  103). 

Older  children  may  have  beef  or  chicken  jelly,  scraped  beef,  etc. 
It  is  well  to  avoid  monotony  of  diet,  lest  the  appetite  fail  entirely. 

CHRONIC      GASTROINTESTINAL    CATARRH     OR 

CHRONIC  ENTEROCOLITIS  AND  CHRONIC 

DIARRHCEA  IN  CHILDREN 

These  conditions  in  children  should  be  treated  by  careful  regulation 
of  the  diet.  Parents  are  apt  to  be  ignorant  in  regard  to  this  matter, 


628  DIET   IN   DISEASES   OF   THE  INTESTINES 

and  strict  written  rules  should  be  furnished  to  them.  The  children 
should  be  fed  at  regular  intervals  at  least  four  times  a  day,  in  order 
that  the  quantity  of  food  given  each  time  may  not  be  too  much.  They 
should  not  be  given  acid  food,  such  as  pickles,  or  indigestible  sub- 
stances of  any  kind,  or  fruit.  Many  patients  do  best  when  put  upon 
a  plain  milk  diet  for  several  weeks,  or,  if  this  is  not  expedient,  pan- 
creatinized  food  may  be  substituted  in  part.  Other  good  temporary 
substitutes  for  plain  milk  are  buttermilk,  whey,  and  koumiss.  Beef 
broth  should  not  be  given  exclusively,  on  account  of  its  occasional 
tendency  to  increase  diarrhoea.  Mutton  or  chicken  broth  is  preferable. 
If  the  stools  contain  much  fat  it  is  an  indication  that  the  pancreatic 
and  biliary  secretions  are  deficient,  and  the  use  of  pancreatin  is  then 
of  special  service. 

These  children  cannot  digest '  sugars,  starches,  or  fats  very  thor- 
oughly, although  cod-liver  oil  may  be  assimilated,  and  when  it  is  it 
constitutes  a  valuable  food.  It  does  not  necessarily  increase  diarrhoea, 
and  it  may  check  it  indirectly  by  improving  nutrition.  Diluted  cream 
may  be  employed  as  a  substitute. 

Among  foods  which  may  be  allowed  to  older  children  as  improve- 
ment begins  are  stewed  oysters,  boiled  or  broiled  fresh  fish,  minced  beef 
and  chicken,  soft-cooked  eggs,  soda  crackers,  bread  and  milk,  toast, 
thin  bread  and  butter,  blancmange,  custard,  junket,  wine  jelly,  and 
cocoa.  Sometimes  the  child  continues  to  emaciate  upon  a  diet  of  ani- 
mal broths  and  meats,  and  fails  to  digest  either  eggs  or  milk.  In  such 
cases  malted  cornmeal  "  mush  "  or  some  simple  cereal,  such  as  barley, 
hominy,  or  rice,  may  be  given  with  malt  extract,  and  among  vegetables 
which  sometimes  may  be  allowed,  if  diarrhoea  has  ceased,  are  asparagus, 
spinach,  stewed  celery,  string  beans,  and  thoroughly  baked  potatoes 
with  a  little  salt  and  butter  well  mixed. 

Hot  water  should  be  recommended  before  meals  if  the  child  will 
take  it.  It  may  be  given  a  faint  flavor  of  some  spice,  such  as  cinna- 
mon or  clove,  and  whey  is  an  excellent  beverage.  Some  children  be- 
come very  fond  of  koumiss,  but  it  is  expensive  unless  homemade  (p. 
94).  Milk  sugar  may  be  added  to  foods  or  beverages  in  considerable 
quantity. 

Many  of  these  young  children  become  strikingly  emaciated,  and,  in 
spite  of  all  dietetic  regimen,  the  skin  is  dry  and  wrinkled,  and  care 
should  be  taken  to  improve  its  nutrition.  This  may  be  done  by  tepid 
baths  before  bedtime  and  gentle  friction,  and  by  inunctions  of  three 
or  four  drachms  of  warm  melted  cocao  butter  or  warm  olive  oil  or  cod- 
liver  oil,  to  be  rubbed  in  over  the  extremities  and  parts  of  the  trunk 
other  than  the  abdomen.  In  this  way  little  if  any  nourishment  can  be 


SIMPLE   ATROPHY  —  MARASMUS  629 

rubbed  into  tbe  circulation,  but  the  main  benefit  of  the  inunction  con- 
sists in  improving  the  condition  of  the  skin  by  local  action,  and  in 
preventing  excessive  heat  loss,  to  which  poorly  nourished  children  are 
prone. 

SIMPLE  ATROPHY  —  MARASMUS 

Marasmus  is  a  form  of  starvation  occurring  chiefly  in  artificially- 
fed  infants,  but  also  in  those  at  the  breast,  in  whom  there  is  great 
wasting  of  the  muscular  and  other  soft  tissues,  and  often  catarrh  of 
the  alimentary  canal.  The  food  is  either  too  limited  in  quantity,  is 
indigestible,  or  else  is  supplied  in  excess  in  a  form  in  which  the  ingre- 
dients are  not  properly  balanced.  Breast-fed  children  are  more  likely 
to  suffer  from  insufficient  quantity,  and  hand-fed  infants  from  im- 
proper quality  of  food  and  overfeeding.  "  Food  upon  which  a  child 
has  thrived  for  three  or  four  months,  perhaps,  can  become  unsuitable, 
and  consequently  lead  to  wasting  if  the  digestive  powers  be  suddenly 
reduced  by  an  intercurrent  disease"  (Louis  Starr).  The  treatment 
of  marasmus  is  therefore  essentially  dietetic,  and  the  reader  is  referred 
to  the  general  directions  for  Infant  Feeding.  No  detail  should 
be  considered  too  trivial  for  the  physician's  personal  attention.  If 
nursed,  the  mother's  or  wet  nurse's  milk  should  be  examined  for  rich- 
ness in  cream  and  curd.  If  hand-fed,  the  most  scrupulous  care  should 
be  taken  to  secure  antiseptic  cleanliness,  and  milk  or  milk  and  meat 
juice  should  be  the  staple  foods.  The  disease  is  commonest  in  the  first 
year  of  life,  but  may  occur  in  the  second,  and  its  effects  in  enfeebling 
the  constitution  may  last  much  longer.  It  is  just  at  this  period  that 
mothers  —  for  reasons  of  supposed  economy  or  expediency  —  are 
tempted  by  seductive  advertisements  to  supplant  the  only  natural  in- 
fant food  (milk)  with  all  sorts  of  prepared  foods.  It  is  because  they 
do  not  know  how  to  prepare  cow's  milk  properly  and  adapt  it  to  the 
baby's  needs  that  they  substitute  or  add  artificial  farinaceous  "baby 
foods/' 

All  milk  should  be  pasteurized  and  pancreatinized  temporarily 
(p.  100),  and  lime  water  or  barley  water  are  the  best  diluents,  the 
former  being  preferred  if  there  is  vomiting  or  acid  eructation.  (For 
correct  dilution  according  to  age,  see  Infant  Feeding).  If  good 
top  milk  cannot  be  obtained,  one  or  two  tablespoonfuls  of  cream  with  a 
teaspoonful  of  milk  sugar  is  to  be  added  to  each  bottle.  Some  infants 
do  better  for  a  short  time  upon  a  cream-and-water  mixture. 

In  other  cases  all  milk  should  be  withheld,  and  expressed  beef 
juice,  diluted  meat  broths,  and  egg  albumen  solution  may  be  used. 


630  DIET   IN   DISEASES   OF   THE  INTESTINES 

Louis  Starr  says :  "  At  eight  or  ten  months  from  two  to  four  fluid 
ounces  of  thin  mutton  or  chicken  broth  free  from  grease  may  be 
allowed  each  day  in  addition  to  the  milk;  at  twelve  months  the  yolk 
of  a  soft-boiled  egg,  rice  and  milk,  and  carefully  mashed  potatoes  with 
gravy;  and  at  the  end  of  the  second  year  a  small  quantity  of  finely 
minced  meat/'  Orange  juice  is  always  wholesome  in  non-diarrhceal 
cases. 

Cod-liver  oil  should  be  given,  but  never  until  the  digestive  func- 
tions are  well  restored,  as  shown  by  the  character  of  the  stools,  the 
absence  of  eructation  and  flatulence,  and  a  clean  tongue.  It  is  to 
be  prescribed  pure,  or  in  one  of  the  emulsions  with  calcium  lacto- 
phosphate. 

Daily  warm  baths  and  inunctions  of  two  or  three  drachms  of  cod- 
liver  oil,  or,  better,  olive  oil,  are  to  be  ordered,  with  fresh  air  in 
abundance. 

MUCOUS    DISEASE  — CHRONIC    PSEUDO-MEMBRA- 
NOUS ENTERITIS  —  MEMBRANOUS  COLITIS 

Pathological  Physiology. —  Mucous  disease  is  an  obstinate  chronic 
affection  in  which  large  quantities  of  thick,  ropy  mucus  are  formed 
in  the  alimentary  canal,  chiefly  in  the  large  intestine.  The  disease  is 
accompanied  by  neurasthenia  and  disorders  of  intestinal  digestion  and 
absorption,  of  greater  or  less  severity. 

The  hypersecretion  results  in  formation  of  long  tube  casts  of  fibri- 
nous  mucus.  The  passage  of  the  casts  is  sometimes  accompanied  by 
severe  paroxysmal  pains,  and  blood  may  appear  in  the  stools.  Chronic 
mucous  disease  is  sometimes  a  sequel  of  the  infectious  diseases  which 
particularly  affect  children,  notably  whooping  cough.  Young  children 
normally  secrete  more  mucus  from  the  intestines  than  do  adults,  and 
the  long  continuance  of  an  irritating  diet  of  improper  food  may  give 
rise  to  hypersecretion.  There  are  a  larger  number  and  variety  of 
bacteria  found  in  the  stools  than  are  usually  present,  but  this  disease 
is  not  definitely  attributable  to  the  action  of  any  one  species.  It  some- 
times is  associated  with  the  presence  of  intestinal  worms.  Not  infre- 
quently there  is  colonic  distention  of  considerable  extent. 

Symptoms. —  The  appetite  is  very  irregular.  It  may  be  exaggerated 
early  in  the  disease,  and  fail  completely  later  on.  The  food  does  not 
nourish,  absorption  being  prevented  by  the  mucus,  and  it  causes  flatu- 
lency and  discomfort.  In  children  especially  emaciation  is  progressive 
and  extreme.  Some  of  the  stools  consist  exclusively  of  mucus,  fatty 
epithelial  cells,  and  granular  detritus,  whereas  others  contain  particles 


MEMBRANOUS  COLITIS  —  DYSENTERY  631 

of  undigested  food,  milk  curds,  meat  fiber,  etc.,  mixed  with  mucus. 

Dietetic  Treatment. —  The  cure  of  this  condition  lies  in  the  most 
rigid  dietetic  treatment,  combined  with  regular  habits  as  to  exercise, 
bathing,  etc.,  and  the  elimination  of  neurotic  factors.  In  grave  cases 
only  predigested  fluid  food  should  be  given,  such  as  pancreatinized 
milk,  meat  juice,  and  egg  albumen.  Beef  tea,  light  broths  of  veal, 
mutton,  or  chicken,  consomme,  or  milk  punch  may  be  allowed.  In 
acute  exacerbations  in  children  it  is  necessary  to  give  no  food  by  the 
stomach  for  six  or  eight  hours,  and  then  commence  to  feed  very  slowly, 
giving  teaspoonful  doses  at  fifteen-minute  intervals.  If  the  child  has 
been  living  for  long  upon  milk  alone,  and  the  stools  show  fat  and  un- 
digested curds,  it  is  best  to  make  a  radical  change  and  proscribe  it 
entirely.  Jacobi  gives  instead  a  mixture  containing  five  ounces  of 
barley  water,  one  to  two  drachms  of  brandy  or  whisky,  the  white  of 
an  egg,  and  a  little  salt  and  cane  sugar.  Dose,  a  teaspoonful  every 
ten  or  fifteen  minutes.  This  is  a  fairly  palatable  mixture.  It  is 
considered  best  to  withhold  all  farinaceous  and  saccharine  articles 
until  some  sign  of  improvement  appears. 

In  adults  membranous  colitis  should  be  treated  by  diet  of  animal 
food,  consisting  of  red  meats  principally,  with  chicken,  fresh  boiled 
fish  and  eggs.  As  cereals,  toast,  milk  crackers,  zwieback,  shredded 
wheat  and  fine  hominy  may  be  eaten  with  very  dilute  cream.  To  be 
avoided  are  vegetables  and  fruits  in  general,  sweets  of  every  kind,  con- 
diments, and  all  salads  and  desserts,  excepting  those  made  with  gela- 
tin, like  blancmange  or  wine  jelly.  Intestinal  irrigation  with  a  two 
per  cent  creolin  solution  is  helpful. 

DYSENTERY 

During  an  attack  of  acute  dysentery  the  patient  should  be  kept 
absolutely  quiet  in  bed,  and  should  not  be  allowed  to  rise  for  the  move- 
ment of  the  bowels,  making  use  of  a  bedpan  instead.  Throughout  the 
active  stage  the  diet  should  be  confined  strictly  to  predigested  fluid  ar- 
ticles. Peptonized  or  pancreatinized  milk,  or  boiled  milk,  pressed- 
meat  juice,  whey,  or  raw  egg  albumen  beaten  with  sherry  and  flavored 
with  nutmeg  are  recommended.  Many  patients  do  well  subsequently 
upon  a  diet  of  raw  scraped  beef  or  meat  balls  (p.  132). 

In  cases  of  acute  dysentery,  and  especially  in  the  amoebic  form,  the 
loss  of  strength,  anaemia,  and  emaciation  progress  very  rapidly,  and  the 
strength  may  be  supported  by  stimulation,  for  which  brandy  is  prefer- 
able to  whisky. 

During  convalescence  the  diet  is  to  be  very  cautiously  increased, 


633  DIET  IN  DISEASES  OF  THE  INTESTINES 

and  confined  to  food  which  is  promptly  and  completely  digested,  leav- 
ing little  residue.  For  this  purpose  animal  food  should  be  eaten 
chiefly,  and  fish,  tender  beefsteak,  roast  beef,  boiled  or  broiled  chicken, 
eggs,  custard,  blancmange,  dry  toast,  junket,  well-boiled  rice,  or  wine 
jelly,  may  be  given.  All  fruits  and  vegetables  should  be  forbidden, 
and  butter  and  cream  taken  sparingly. 

Chronic  dysentery  is  often  best  treated  by  an  exclusive  milk  diet 
of  from  two  and  a  half  to  three  quarts  a  day,  with  rest  in  bed  or 
on  the  lounge.  In  other  cases  rare  steak  or  roast  beef  or  chicken 
and  egg  albumen  may  be  allowed,  with  dry  toast,  zwieback,  or  crack- 
ers. The  milk  and  meat  diet  may  advantageously  be  combined. 

The  stools  should  be  examined  microscopically  every  day  or  two 
to  ascertain  the  presence  of  undigested  fragments  of  milk  curds  or 
meat,  oil  globules,  mucus,  blood,  etc.  If  improvement  does  not  occur, 
the  patient  may  be  put  upon  a  diet  of  egg  albumen  with  beef  juice, 
or  some  of  the  preparations  of  beef  meal  (p.  132)  or  peptonoids,  with 
pancreatinized  milk.  Eeturn  to  solid  diet  should  be  gradual,  and 
conducted  on  the  lines  directed  for  convalescence  from  typhoid  fever 
(p.  483).  Colonic  astringent  irrigations  are  indicated. 

ACUTE  INTESTINAL  OBSTRUCTION 

Many  of  these  cases  demand  immediate  operation,  but  if  for  any 
reason  this  is  not  performed  in  cases  of  partial  obstruction,  nothing 
should  be  given  by  the  mouth.  If  any  food  be  taken  it  decomposes, 
and  even  drink  may  excite  severe  vomiting.  The  patient  may  be 
nourished  by  the  rectum,  and  thirst  relieved  by  injection  of  a  pint 
of  lukewarm  water  with  a  teaspoonful  of  salt  into  the  rectum.  If 
the  latter  is  irritable  a  smaller  quantity  should  be  employed,  and  more 
often  given.  Another  method  of  relieving  thirst  is  to  inject  a  pint 
or  two  of  warm,  sterilized  salt  solution  of  the  above  strength  into 
the  cellular  tissue  beneath  the  skin,  after  the  manner  of  the  hypo- 
dermoclysis  recommended  in  cholera  (p.  499). 

If  the  obstruction  is  overcome  without  operation,  the  diet  should 
be  increased  very  slowly,  giving  only  fluid  nourishment  by  the  mouth 
for  two  or  three  days,  or  until  all  symptoms  have  subsided. 

The  fluid  food  should  consist  of  beef  juice,  broths,  egg  albumen, 
and  simple  farinaceous  gruels.  Milk,  if  not  completely  absorbed, 
forms  too  bulky  feces. 

The  symptoms  of  profound  collapse,  thready  pulse,  etc.,  depend 
not  upon  the  local  condition  of  obstruction,  but  upon  saprsemic  in- 
toxication from  toxins  produced  by  decomposition  of  retained  food. 


CHRONIC   CONSTIPATION  633 

This  statement  is  corroborated  by  the  prompt  relief  which  sometimes 
succeeds  emptying  the  bowel  after  removal  of  the  obstruction  and  the 
use  of  lavage  and  irrigation  with  hot  salt  water  (106°  F.).  (See 
Autointoxication,  p.  621.) 

CHRONIC  CONSTIPATION 

Physiology. —  The  periodic  daily  evacuations  of  the  bowels  are  de- 
termined by  peristaltic  contractions  of  the  muscular  wall  of  the  in- 
testines excited  by  their  contents.  This  process  is  accomplished  by 
rhythmical  vermicular  contractions  of  the  intestinal  wall  which  are 
reflex  in  character  and  stimulated  in  different  degrees  by  the  (1)  bulk 
and  chemical  combination  of  the  thick  fluid  food  or  chyme  derived 
from  the  stomach  and  by  (2)  the  various  digestive  secretions,  namely, 
the  intestinal  and  pancreatic  juices  and,  especially,  the  bile.  This 
peristalsis  is  more  active  in  the  small  than  in  the  large  intestine, 
for  it  has  the  triple  function  of  (1)  mixing  the  food  and  digestive 
fluids;  (2)  bringing  the  whole  mass  into  contact  with  a  large  surface 
for  absorption;  and  (3)  propelling  the  residue  towards  the  large  in- 
testine. Simultaneously  the  local  blood  current  is  increased.  The 
vessels  and  lymphatics  in  the  intestinal  wall  and  mesentery  become 
distended  by  absorption  of  food  products.  The  increase  in  volume 
and  flow  of  the  blood  also  stimulates  peristaltic  contractions. 

Towards  the  lower  end  of  the  small  intestine  the  food  is  found 
diminished  in  volume  by  absorption,  and  the  mass  is  consequently 
somewhat  drier.  The  ileo-caecal  valve  is  periodically  relaxed  by  reflex 
mechanism,  and  the  peristalsis  of  the  small  intestine  propels  the 
food  onward  into  the  large  intestine,  where  further  absorption  takes 
place,  and  the  solid  residue  is  more  slowly  moved  towards  the  sigmoid 
flexure.  Here  it  remains  and  accumulates  until  a  certain  bulk  is 
gathered,  which  by  pressure  or  distention  excites  the  reflex  mechanism 
of  defecation.  This  mechanism  employs  a  number  of  muscles,  hence 
the  need  of  a  controlling  nerve  center,  which  is  found  in  the  lumbar 
region  of  the  spinal  cord. 

Constipation,  when  not  due  to  intestinal  obstruction,  is  dependent 
upon  lack  of  peristalsis,  as  diarrhoea  is  due  to  excessive  peristalsis. 

Many  persons  are  ignorant  of  what  constitutes  a  normal  stool. 
The  custom  of  using  patent  water-closets  often  prevents  them  from 
seeing  the  stool,  and  they  are  unable  correctly  to  estimate  its  amount 
or  character.  A  little  accumulation  of  residue  left  over  each  day  will 
presently  cause  very  uncomfortable  constipation.  The  normal  stool 
should  weigh  about  five  or  five  and  a  half  ounces,-  of  which  only  one 


634  DIET   IN  DISEASES  OF   THE  INTESTINES 

and  a  half  ounce  is  solid  matter.  It  should  constitute  a  sausage- 
shaped  mass,  in  all  about  six  or  eight  inches  in  length.  (See  Feces 
and  Food,  p.  401.) 

Pathological  Physiology. —  Constipation  may  result  from  one  or 
more  of  the  following  causes  related  to  diet:  1.  Insufficient  quan- 
tity of  solid  food.  2.  Too  highly  nutritious  or  concentrated  food.  3. 
Insufficient  liquid  ingested.  4.  Astringent  food  and  drink.  5.  In- 
digestible food.  6.  Lack  of  digestive  secretions.  7.  Irregularity  in 
diet.  8.  Obstruction  from  overeating.  9.  Lack  of  peristalsis.  10. 
Lack  of  exercise. 

1.  Insufficient  food  is  one  of  the  most  common  causes  of  consti- 
pation.    In  prolonged  starvation  the  bowels  cease  to  move  entirely. 
Persons  who  eat  sparingly  have  too  little  bulk  of  food  to  excite  the 
normal  peristaltic  motion  of  the  intestines,  and  the  waste  products  ac- 
cumulate in  consequence. 

2.  Too   highly   nutritious   or   concentrated   food,    such    as    richly 
seasoned   meats,  milk,  meat  extracts,  peptonized  or  pancreatinized 
fluids,  etc.,  being  almost  completely  absorbed,  leave  insufficient  residue 
of  waste  matter.     Peristalsis  is  therefore  either  not  excited  or  the 
contracting  intestinal  wall  has  insufficient  bulk  of  material  to  seize 
upon  and  propel. 

3.  Insufficient  liquid  ingested  causes  constipation  for  three  reasons : 
(1)   The  chyme  is  not  kept  fluid  enough  to  be  mingled  thoroughly 
with  the  digestive  juices.     (2)   The  intestinal  walls  become  too  dry 
and  friction  over  the  hardened  fecal  masses  is  increased,  making  it 
difficult  to  propel  them.     (3)   There  is  less  fluid  absorbed  by  the 
blood,  and  consequently  the  digestive  juices  and  intestinal  mucus  are 
reduced  in  quantity  and  altered  in  quality. 

4.  Astringent  food  or  drinks,  such  as  tea,  brandy,  claret,  or  black- 
berry juice,  constipate  by  checking  the  mucous  and  other  secretions, 
thereby  increasing  friction  within  the  intestinal  wall. 

5.  Indigestible  food  may  be  so  hard  and  bulky  as  to  be  imper- 
fectly acted  upon  by  peristalsis  and  incompletely  mingled  with  the 
digestive  juices,  or  it  may  give  rise  to  abnormal  fermentation  and  pro- 
duction of  substances  which  inhibit  absorption  and  peristalsis. 

6.  Lack  of  digestive  secretions  in  normal  proportion  or  serious 
alterations  in  their  composition  retard  digestion  and  lessen  peristalsis. 

7.  Irregularity  in  diet  or  in  the  intervals  of  taking  food,  eating 
too  hastily,  imperfect  mastication,  and  great  variations  in  the  quan^ 
tity  of  food  eaten,  all  tend  to  disorder  digestion  by  disturbing  the 
natural  rhythm  of  its  various  stages,  and  especially  the  periodicity  of 
defecation. 


CHRONIC   CONSTIPATION  635 

8.  Obstruction  from  overeating,  particularly  in  children,  may  cause 
constipation   from   the   accumulation   of   larger   quantities   of   waste 
matter  than  the  intestinal  muscles  have  power  to  propel. 

9.  Lack  of  peristalsis  occurs  through  enfeebled  intestinal  muscles 
or  imperfect  nerve  stimulation. 

10.  Lack  of  exercise  fails  to  stimulate  the  circulation,  both  gen- 
eral and  local,  to  stimulate  peristalsis  by  the  natural  movements  of 
the  body,  especially  of  the  abdominal  muscles,  and  to  stimulate  the 
flow  of  bile. 

Constipation  is  not  infrequently  a  constitutional  habit  or  family 
peculiarity,  running  through  several  generations.  It  is  provoked  by 
sedentary  habits  and  neglect  of  the  calls  of  Nature,  and  it  is  the 
usual  accompaniment  of  impoverished  conditions  of  the  blood,  malnu- 
trition, especially  anaemia,  neurasthenia,  hysteria,  and  chronic  diseases 
of  the  liver  and  stomach.  It  also  is  present  in  connection  with  many 
acute  fevers,  and  the  habit  of  the  perpetual  consumption  of  drugs 
of  many  varieties  may  occasion  it. 

Weakness  of  the  muscles  of  the  intestine  and  abdominal  wall  are 
common  factors  in  the  production  of  constipation.  This  symptom  is 
therefore  present  in  obesity,  overdistention  of  the  abdominal  wall 
during  pregnancy,  and  in  atony  of  the  large  intestine  and  chronic 
diseases  of  its  mucous  membrane.  It  is  also  produced  by  obstruc- 
tion from  the  pressure  of  tumors,  accumulation  of  scybalas  from 
impaction  of  foreign  bodies  in  the  bowel,  stricture,  localized  atony  of 
the  sigmoid  flexure,  extreme  incurvation  of  the  coccyx,  dilatation  of 
the  colon,  uterine  displacements,  etc. 

Symptoms. —  In  all  common  cases  the  symptoms  accompanying  con- 
stipation are  debility  and  lassitude,  while  more  or  less  mental  de- 
pression is  present  in  persons  of  nervous  or  hypochondriacal  temper- 
ament. When  it  occurs  in  the  course  of  chronic  insanity  it  increases 
languor,  moroseness,  and  irritability  of  temper,  and  not  seldom  ex- 
cites acute  and  violent  symptoms.  As  a  result  of  the  accumulation 
of  waste  matter  in  the  lower  bowel,  visceral  displacements  may  oc- 
casionally result,  or,  if  they  already  exist,  may  be  increased.  Sacral 
neuralgia  is  sometimes  produced,  and  hemorrhoids  from  congestion 
of  the  rectal  veins  may  occur.  Occasionally  constipation  may  result 
from  malformations  of  the  intestine  —  adhesions  which  bind  loops 
and  coils  of  the  intestine  in  abnormal  positions  and  interfere  with 
peristaltic  movement.  The  impacted  feces  accumulate  in  the  colon 
and  are  found  chiefly  in  the  sigmoid  flexure,  but  they  also  may  form 
large  tumors  in  the  hepatic  or  splenic  flexure,  or  even  in  the  right 
inguinal  region.  In  aged  persons  sacculi  of  the  colon  may  become 


636  DIET   IN  DISEASES   OF   THE  INTESTINES 

permanently  distended,  and  scybalae  become  calcified  as  enteroliths. 
A  channel  is  sometimes  bored  through  the  impacted  masses  of  fecal 
material,  and  the  long-continued  constipation  will  give  rise  to  diar- 
rhoea. The  fecal  mass  acts  as  a  local  irritant,  and  diarrhreal  stools 
pass  through  the  channel. 

Chronic  constipation  may  sometimes  give  rise  to  acute  attacks  of 
localized  pain  and  considerable  fever  (104°  F.).  These  attacks  may 
simulate  appendicitis,  localized  peritonitis,  or  other  acute  abdominal 
diseases.  In  every  case  of  chronic  constipation  the  abdomen,  and  if 
necessary,  the  rectum,  should  be  examined  thoroughly. 

Dietetic  Treatment. —  Before  ordering  the  diet  for  chronic  consti- 
pation, the  patient  should  be  interrogated  minutely  as  to  his  daily 
habits  of  life,  such  as  occupation,  hours  for  meals,  exercise,  recrea- 
tion, and  sleep,  the  kinds  of  foods  and  quantity  usually  eaten,  the 
amount  and  kinds  of  fluids  drunk,  hour  for  going  to  stool,  the  use 
of  stimulants  and  tobacco,  and  presence  of  mental  worry  or  anxiety. 

The  principles  of  dietetic  treatment  of  chronic  constipation  are 
based  upon  supplying  digestible  food,  which  will  excite  peristalsis 
either  by  its  bulk  or  its  physical  and  chemical  properties.  Vegetable 
food  in  general,  as  distinguished  from  proteid  diet,  furnishes  a 
much  larger  proportion  of  waste.  Herbivorous  animals  have  more 
abundant  evacuations  than  do  carnivores. 

Following  is  a  list  of  common  foods  discussed  in  their  relation 
to  constipation: 

Vegetables. —  The  cellulose  of  starchy  foods  is  difficult  of  digestion 
and  of  comparatively  little  nutrient  value  for  man;  hence  it  yields 
a  considerable  quantity  of  waste  material.  This  is  true  of  the  starch 
granules  of  potatoes,  corn,  peas,  beans,  etc. 

Other  vegetables  which  leave  a  large  residue  after  digestion  are 
tomatoes,  spinach,  lettuce,  asparagus,  salsify,  cabbage,  turnips,  rhu- 
barb, and  celery.  Eggplant,  tomatoes,  and  cucumbers  seem  to  possess 
slight  special  laxative  properties,  the  three  latter  partly  on  account  of 
the  seeds  which  they  contain.  Spanish  onions,  boiled,  are  laxative. 

Cereals. —  The  various  cereals  used  for  bread  when  coarsely  ground 
contain  a  large  proportion  of  the  external  envelope  of  the  grains, 
which  is  more  or  less  hard  and  rough,  and  by  its  presence  in  the 
intestine  mechanically  stimulates  peristalsis. 

For  the  above  reasons  the  following  articles  of  diet  tend  to  overr 
come  constipation :  Coarse  Graham  bread,  rye  bread,  wheatena, 
wheaten  grits,  cornmeal,  Indian  meal,  oatmeal,  brown  or  "  whole- 
meal "  broad,  Boston  brown  bread,  shredded  wheat. 

Molasses  and  honey  added  to  bread  are  laxative.     Gingerbread,  es- 


CHRONIC   CONSTIPATION  637 

pecially  for  children,  is  sometimes  efficacious.  With  some  persons 
the  substitution  of  milk  sugar  (lactose)  for  cane  sugar  proves  laxative. 

Beverages. —  Coffee,  beer,  new  cider,  and  unfermented  grape  juice 
are  somewhat  laxative. 

Oils. —  Olive  oil  and  cod-liver  oil,  if  taken  at  bedtime  into  an 
empty  stomach,  are  laxative  for  some  persons,  particularly  children, 
and  butter  is  slightly  so  for  young  infants. 

Adults  may  take  a  couple  of  tablespoonfuls  of  best  Lucca  oil  with 
each  meal,  eating  it  with  fresh,  vegetables,  such  as  beets  or  lettuce,  or 
mixing  it  with  potatoes. 

Fruits. —  Fruits  are  laxative,  either  because  they  contain  indiges- 
tible seeds,  which  act  mechanically  in  the  intestine  (e.  g.,  figs,  ber- 
ries), or  because  the  vegetable  acids  and  salts  which  they  furnish 
upon  being  absorbed  stimulate  the  digestive  secretions  and  peristalsis. 

Fruits  which  are  laxative  on  account  of  their  seeds  are  figs,  black- 
berries, raspberries,  strawberries,  huckleberries,  blueberries.  Grapes 
eaten  in  large  numbers  without  the  seeds  are  laxative. 

Fruits  having  special  laxative  properties  through  chemical  action 
are  apples,  pears,  peaches,  nectarines,  apricots,  oranges,  shaddocks, 
cherries,  prunes,  plums.  Many  fruits  act  in  both  the  above  ways. 
Eaisins,  prunes,  prunelles,  and  apples  leave  considerable  bulk  of 
waste  matter  after  digestion.  Olives  are  laxative  by  virtue  of  their 
oil. 

Fruit  is  always  more  laxative  when  eaten  between  meals  or  some 
time  —  say,  half  an  hour  —  before  breakfast  or  late  at  night.  It 
then  enters  the  intestine  more  promptly,  and  it  is  not  retarded  in 
its  effect  by  the  presence  of  other  articles  of  diet.  Its  action  is 
furthered  by  drinking  a  tumblerful  or  two  of  water  after  eating  it. 

With  many  persons  constipation  may  be  prevented  by  eating  two 
or  three  oranges  or  the  juice  of  a  grape-fruit  before  breakfast.  The 
latter  is  often  sour,  and  sugar  may  be  required  to  make  it  palatable. 
This  is  a  disadvantage  for  those  who  have  flatulent  dyspepsia  or  gout. 
Instead  of  sugar,  the  bitterness  may  be  disguised  by  a  little  maraschino 
or  rum  poured  upon  the  cut  fruit.  A  half  dozen  dried  figs  or  a 
dozen  or  so  of  French  prunes  eaten  at  intervals  during  the  day,  when 
the  stomach  is  empty,  produce  a  laxative  effect.  These  fruits  in  smaller 
quantities  are  very  good  for  children.  In  some  cases  the  breakfast 
may  be  confined  exclusively  to  fruits  for  two  or  three  weeks.  It  is 
important  to  prescribe  definitely  the  quantity  of  fruit  to  be  eaten. 
Many  patients  will  state  that  they  eat  fruit  daily  for  breakfast,  when 
perhaps  they  take  half  an  orange,  whereas  they  really  need  the  juice 
or  four  or  five  oranges  squeezed  into  a  glass  and  drunk  with  Vichy. 


638  DIET  IN  DISEASES  OF  THE  INTESTINES 

Cooked  Fruits. —  With  many  persons  having  imperfect  digestion 
raw  fruits  disagree,  and  since  their  laxative  properties  are  not  much 
weakened  by  being  cooked,  it  is  better  to  eat  them  in  that  form. 
Stewed  prunes,  or  figs,  or  apples  either  stewed  or  baked,  are  very 
easy  of  digestion,  and  the  latter  may  often  be  eaten  by  invalids  in 
whom  the  digestive  organs  are  very  weak.  Cooking  berries  or  other 
suitable  fruits  by  stewing  renders  them  more  digestible,  and  does 
not  impair  their  nutritive  qualities.  The  principal  objection  to  cooked 
fruits  is  that  they  usually  require  so  much  sugar  to  make  them 
palatable  that  they  may  cause  flatulency.  A  little  bicarbonate  of 
sodium  will  neutralize  the  acidity,  and  saccharin  may  be  added  in- 
stead of  sugar. 

Canned  or  dried  fruits  and  fruits  preserved  in  sirups  are  of  little 
value  for  constipation.  (Dried  figs  and  prunes  form  an  exception.) 

A  few  fruits,  like  the  banana  and  date,  are  apt  to  cause  constipation. 

yuts. —  Xuts,  especially  English  walnuts,  butternuts  and  almonds, 
are  excellent  laxatives,  partly  from  their  bulky  residue  and  in  part 
from  the  oils  which  they  contain. 

Eegulin  is  a  preparation  of  sea  algae,  agar-agar  (gelatina  saponica) 
devised  by  Prof.  Adolf  Schmidt,  with  20  per  cent  of  an  aqueous  solu- 
tion of  extract  of  cascara.  It  is  markedly  hygroscopic,  consisting  of 
a  gelose  that  absorbs  moisture,  and  when  added  to  soups,  purees,  etc., 
and  eaten  as  a  food,  it  passes  practically  unaltered  to  the  intestine, 
where  it  adds  to  the  bulk  of  the  feces,  keeps  them  uniformly  moist 
and  aids  peristalsis. 

Strong  coffee  is  laxative  with  some  persons. 

Water. —  Copious  draughts  of  either  very  hot  or  cold  water,  two 
or  three  tumblerfuls,  should  be  taken  before  retiring  and  on  rising. 
Many  persons,  from  a  belief  that  water  drunk  with  meals  is  injurious, 
abstain  from  it  and  forget  to  take  liquid  between  meals,  and  become 
constipated  in  consequence.  If  they  happen  to  lose  water  by  free 
perspiration  also,  the  difficulty  is  enhanced.  Such  patients  should 
be  advised  to  drink  water  freely,  as  above  indicated.  It  also  aids 
digestion  to  take  a  tumblerful  of  hot  water  about  an  hour  after  a 
meal  unless  the  gastric  juice  is  feeble  in  acidity.  The  stomach  con- 
tents becoming  somewhat  thickened  by  loss  of  fluid  through  the  pyloric 
orifice  or  by  direct  absorption  through  its  own  wall,  are  digested 
better  by  being  diluted  again.  The  temperature  of  the  water  drunk 
makes  little  difference  as  far  as  constipation  is  concerned.  Cold  water 
is  wanned  and  hot  water  is  cooled  by  the  resophagus,  so  that  upon 
reaching  the  stomach  it  is  nearly  of  the  normal  body  temperature,  no 
matter  how  much  it  differs  from  this  when  swallowed,  provided  it  has 


CHRONIC   CONSTIPATION  639 

been  taken  slowly.  If  swallowed  in  large  draughts  it  does  affect  the 
stomach  temperature  for  a  few  moments,  but  it  is  soon  brought  to  the 
normal  body  temperature  again  (p.  377). 

When  patients  will  not  drink  enough  plain  water  (i.  e.,  from  6 
to  8  or  more  tumblerfuls  a  day),  they  may  be  induced  to  take  lemonade 
or  water  flavored  with  some  aromatic.  A  few  cloves  put  in  a  tumbler 
of  boiling  water  and  allowed  to  steep  overnight  impart  their  flavor 
to  the  fluid,  which  may  be  drunk  on  rising  in  the  morning. 

Patients  living  in  localities  where  the  natural  water  is  impregnated 
with  lime  salts,  should  obtain  lime-free  water,  such  as  Poland  or 
Manitou. 

Summary  of  the  Most  Useful  Foods  for  Chronic  Constipation. — 
Abundant  water,  Graham  bread,  coarse  brown  or  bran  bread,  oat- 
meal, butter,  fresh  green  vegetables  (lettuce,  spinach,  Brussels  sprouts, 
cabbage,  celery,  rhubarb,  etc.),  prunes,  figs,  apples  (cooked  or  raw), 
peaches,  berries,  buttermilk,  apple  cider,  olive  oil,  koumiss,  honey, 
molasses,  English  walnuts,  almonds. 

Foods  to  be  Avoided. —  Persons  suffering  from  habitual  constipa- 
tion do  well  to  give  up'  the  following  articles :  Eggs,  milk,  sweets, 
pastry,  puddings  made  of  simple  amylaceous  substances  —  such  as 
rice,  sago,  etc. —  fried  foods,  rich  gravies,  sauces,  curry,  strong  condi- 
ments, pickles,  cheese,  tea,  sour  or  red  wines. 

AIDS  TO  DIETETIC  TREATMENT 

It  is  an  important  and  infallible  rule  in  cases  of  chronic  constipa- 
tion that  hygienic  as  well  as  dietetic  treatment  should  supersede  the 
use  of  medicine.  It  is  very  necessary  to  establish  a  uniform  hour 
for  going  to  stool  each  day,  and  all  efforts  at  straining  should  be 
avoided.  Exercise  in  moderation  should  be  insisted  upon,  such  as 
walking  at  least  an  hour  or  two  twice  a  day,  but  of  exercise  in  the 
open  air,  horseback  riding  is  most  beneficial.  One  or  two  rides  a 
week  are  much  better  than  none.  Many  persons  find  improvement 
from  bicycling.  Tight  lacing  and  constriction  of  the  abdomen  by 
tight  belts  should  be  avoided,  and  also  sitting  long  in  positions  com- 
pressing the  abdomen.  Very  obese  persons,  however,  with  pendulous 
abdominal  walls  should  wear  a  binder.  Much  good  may  be  accom- 
plished by  elementary  instruction  in  calisthenics,  in  which  special 
attention  is  paid  to  deep  respiratory  movements  of  the  diaphragm, 
and  abdominal  muscles.  Mastication  should  be  thorough. 

Eegularity  should  be  observed  in  habits  of  life,  in  hours  of  sleep, 
and  of  meals.  Many  business  men  whose  daily  routine  of  early 
rising,  exact  hours,  and  evening  dinners  is  disturbed  on  Sundays  by 


640  DIET  IN  DISEASES  OF  THE  INTESTINES 

late  breakfast  and  a  noon  dinner,  find  that  the  regular  habit  of  the 
bowels  is  interrupted  at  the  first  of  the  week,  and  in  consequence 
may  suffer  for  a  day  or  two  from  headache  and  "biliousness." 

Massage  of  the  abdominal  muscles  is  very  useful  for  constipation, 
and  both  percussion  or  mechanical  vibration  and  kneading  are  to  be 
used.  It  should  be  performed  in  the  direction  of  the  colon,  com- 
mencing low  down  on  the  right  side  of  the  abdomen,  ascending  to 
the  ribs,  crossing  to  the  left,  and  descending  upon  the  left  side  to 
the  sigmoid  flexure.  This  mechanical  movement  not  only  pushes 
along  the  intestinal  contents,  if  the  abdominal  wall  be  not  too  fat 
or  rigid,  but  it  stimulates  peristalsis  by  reflex  action.  If  possible, 
it  should  be  given  in  the  morning  before  rising,  and  at  first  daily, 
for  twenty  or  thirty  minutes,  but  later  every  other  day.  The  treat- 
ment should  be  continued  for  a  month  or  more.  Obstinate  cases 
have  been  cured  in  this  manner,  and  the  method  is  especially  serv- 
iceable for  very  obese  patients. 

Some  persons  derive  aid  from  manipulating  the  abdominal  wall 
for  themselves  while  lying  in  bed  in  the  morning.  A  large  wooden 
ball  like  a  croquet  ball  may  be  rolled  over  the  abdomen  for  five  or 
ten  minutes  every  morning,  pressing  it  in  deeply  in  the  direction  of 
the  colon.  This  sometimes,  in  thin  subjects,  promotes  the  movement 
of  the  intestinal  contents. 

Medicines. —  Discussion  of  the  medicinal  treatment  of  constipa- 
tion is  not  within  the  scope  of  this  work,  but  the  practice  of  contin- 
ually taking  laxatives  and  strong  cathartics  cannot  be  condemned  too 
strongly.  The  constant  daily  overexcitation  of  the  bowels  by  such 
remedies  as  aloes  produces  a  deplorable  condition  in  which  the  bowels 
refuse  to  act  at  all  without  increasing  dosage. 

The  majority  of  such  cases  may  be  cured  in  time  by  diet,  but  the 
rules  should  be  laid  down  distinctly,  and  the  patient  must  exercise 
patience  and  care  in  adhering  to  them.  I  have  been  able  often  to 
relieve  patients  who  for  several  years  had  depended  upon  strong 
cathartic  pills  or  enemata,  by  stopping  all  medicine,  and  enforcing 
simple  dietetic  rules,  especially  in  regard  to  drinking  abundant  liquid 
and  eating  laxative  and  bulky  food.  They  often  think  that  a  daily 
movement  is  absolutely  necessary,'  and  the  worry  and  nervousness 
which  its  absence  occasions  increases  the  difficulty.  They  should  be 
reassured,  and  told  not  to  be  concerned  if  the  bowels  do  not  move 
at  first  for  two  days,  and  that  if  they  do  not  have  an  unaided  passage 
after  that  interval  they  can  certainly  be  relieved,  and  diet  and  regimen 
will  succeed  in  time  if  persistently  followed. 

In  obstinate  cases  when  diet  does  not  succeed  alone,  attention  to 


CONSTIPATION   IN    INFANTS   AND   CHILDEEN  641 

its  regulation  will  enable  the  patient  to  obtain  the  desired  result 
with  mild  and  decreasing  doses  of  simple  saline  laxatives  such  as 
Congress,  Crab  Orchard,  Mt.  Clemens,  Apenta,  Hunyadi,  or  Eubinat 
water,  in  lieu  of  strong  cathartic  pills,  or  patent  medicines. 

Tobacco. —  Moderate  tobacco  smoking  increases  peristalsis.  Some 
men  become  constipated  when  deprived  of  their  after-breakfast  cigar. 
The  effect  of  tobacco  is  not  constant,  however,  and  by  disordering 
digestion  excessive  smoking  may  be  an  indirect  cause  of  constipa- 
tion. In  those  in  whom  it  acts  favorably  upon  the  bowels,  a  good 
cigar  is  usually  better  than  any  other  form  of  the  weed. 

Bathing. —  A  daily  morning  cold  bath  followed  by  vigorous  fric- 
tion of  the  skin  is  of  great  service. 

Electricity. —  Faradization  of  the  abdominal  walls  is  frequently 
employed,  but,  owing  to  the  fact  that  the  electric  current  when  applied 
superficially  radiates  over  the  skin  without  penetrating  to  any  ex- 
tent beneath  the  surface,  it  cannot  be  expected  to  reach  the  intes- 
tinal wall.  A  much  better  method  of  applying  a  faradic  current 
consists  of  introducing  one  electrode  for  several  inches  into  the 
rectum,  while  the  other  is  moved  about  over  the  surface  of  the  ab- 
dominal muscles.  In  this  manner  these  muscles  may  be  made  to 
contract  and  move  the  intestines  to  some  extent,  and  it  is  possible 
for  a  portion  of  the  current  to  pass  through  the  sigmoid  flexure.  If 
carefully  adjusted,  the  application  of  the  current  gives  rise  to  no  pain 
or  discomfort. 

Bandaging. —  In  very  obese  persons,  who  are  liable  to  suffer  from 
constipation,  the  pendulous  and  relaxed  abdominal  wall  should  be 
supported  with  an  abdominal  bandage.  The  same  treatment  may 
give  comfort  when  the  wall  is  much  distended  in  childbearing  or  by 
the  presence  of  large  abdominal  tumors  or  accumulations  of  ascitic 
or  ovarian  fluid. 

CONSTIPATION  IN  INFANTS  AND  CHILDREN 

In  earliest  infancy  from  two  to  three  daily  evacuations  from 
the  bowels  are  considered  a  normal  number,  but  in  childhood,  as 
in  adults,  one  passage  is  normal.  In  later  infancy,  constipation  is 
exceedingly  common  on  account  of  the  milk  diet,  and  bottle-fed 
babies  are  more  subject  to  it  than  sucklings.  The  small  intestine 
is  relatively  longer  than  in  the  adult,  the  large  intestine  easily  be- 
comes distended,  the  pelvis  is  relatively  small,  and  peristalsis  is  usually 
less  vigorous,  owing  to  a  less  powerful  musculature  than  obtains  in 

adults. 

43 


642  DIET   IN  DISEASES  OF   THE   INTESTINES 

When  constipation  is  present  in  an  infant  at  the  breast  the  milk 
may  be  too  rich  in  casein  and  deficient  in  fat,  salts,  and  sugar.  This 
may  be  due  to  a  constipated  habit  of  the  mother,  and  laxative  foods 
should  be  given  to  her  rather  than  medicines  to  the  child.  If  the 
child  is  nursing  a  wet  nurse,  it  may  be  best  to  change  to  another  in 
perhaps  an  earlier  stage  of  lactation,  or  one  whose  milk  is  less  rich 
in  proteid. 

If  the  infant's  stools  consist  of  dry  and  brittle  scybalse  it  should 
be  given  more  water  to  drink,  or  a  little  oatmeal  water,  which  is 
laxative.  Other  simple  and  oftentimes  effectual  remedies  are  from 
half  to  a  teaspoonful  of  olive  oil,  molasses,  malt,  melted  sugar,  or 
butter,  and  a  few  teaspoonfuls  of  orange  juice. 

In  the  case  of  hand-fed  babies  when  the  milk  forms  large  and 
hard  curds,  and  when  the  proportion  of  cream  is  too  small,  the  addi- 
tion of  water  and  cream  may  remedy  the  evil. 

As  an  occasional,  but  not  habitual,  simple  remedy  for  constipa- 
tion in  such  cases  relief  may  be  obtained  by  making  a  mixture  of  a 
tablespoonful  of  whole-meal  gluten  flour  in  a  pint  of  water,  boiling 
for  three  hours  to  a  thick  mass,  and  adding  a  teaspoonful  of  the 
mixture,  unstrained,  to  each  feeding  bottle. 

Artificial  foods,  "  prepared "  or  "  proprietary "  foods,  and  con- 
densed milk  are  more  likely  to  excite  diarrhoea  than  constipation,  but 
it  should  be  remembered  that  they  may  cause  the  latter,  and  the  con- 
tinual use  of  coarse  food  or  cathartics,  or  of  large  enemata,  over- 
stimulates  the  bowel  and  results  in  constipation. 

When  it  is  necessary  to  use  enemata  they  should  be  small,  and 
not  too  frequently  given.  From  ten  to  thirty  drops  of  glycerin  in 
two  teaspoonfuls  of  water  is  quite  sufficient  for  a  young  nursing 
infant.  The  glycerin,  by  virtue  of  its  hygroscopic  power,  abstracts 
water  from  the  rectal  mucous  membrane,  causing  hyperaemia,  which 
in  turn  excites  peristalsis.  A  simple  injection  of  two  teaspoonfuls 
of  cold  water  containing  a  pinch  of  salt  is  often  successful. 

Suppositories  also  may  be  used.  They  should  be  small,  conical 
in  shape,  and  well  oiled  before  being  inserted.  They  may  be  made 
of  glycerin,  soap,  molasses  candy  (Fruitnight),  or  gluten. 

For  older  children,  from  three  years  up,  some  one  or  more  of  the 
following  foods  should  be  included  in  the  menu:  by  this  means  it 
will  be  possible  to  do  without  castor  oil,  senna,  rhubarb,  strong  ene- 
mata. and  other  remedies  which  are  constantly  abused: — 

Foods  Recommended. —  Oatmeal,  corn  bread,  cracked  wheat,  por- 
ridge, wheaten  bread  made  of  unbolted  flour,  bran  bread  soaked  in 
warm  milk,  gingerbread,  bread  and  molasses  (not  sirup),  brown 


HEMORRHOIDS  —  APPENDICITIS  643 

bread  and  honey,  stewed  prunes,  baked  apples,  stewed  figs,  olive  oil, 
cod-liver  oil,  fresh  green  vegetables,  orange  juice,  peaches,  whey, 
butter,  cream  and  buttermilk. 

Foods  Forbidden. —  Certain  foods  should  be  forbidden  absolutely  to 
older  children,  such  are  cheese,  dry  fruits  (except  figs  and  prunes), 
fruits  having  small  seeds  or  edible  skins  (like  the  blueberry),  spices, 
pickles,  nuts,  raisins,  dried,  salted,  or  preserved  foods  of  all  kinds, 
canned  corn,  sweets,  candies,  griddle  cakes,  and  excess  of  farinaceous 
foods.  All  articles  likely  to  produce  flatulent  dyspepsia  should  be 
withheld.  Children  on  a  mixed  diet  do  well  to  avoid  starchy  foods 
and  take  more  broths  and  soups.  Variety  in  the  diet  is  desirable. 

Children  should  be  trained  to  go  to  stool  at  regular  hours,  and 
should  be  taught  the  evil  consequences  of  neglect  to  respond  to  the 
calls  of  Nature.  School-teachers  should  not  detain  them  at  their 
lessons  when  they  are  inclined  to  seek  the  closet.  Water-closets 
or  privies  are  sometimes  dark,  cold,  and  otherwise  disagreeable,  so 
that  children  dread  going  to  them. 

Abdominal  massage  is  very  helpful  in  overcoming  chronic  con- 
stipation in  young  children.  It  may  be  performed  two  or  three 
times  a  day  for  five  minutes  with  the  fingers  of  a  warm,  dry  hand, 
which  move  the  integument  and  abdominal  wall  over  the  intestine. 
The  treatment  should  be  very  gentle,  and  if  the  muscular  wall  is 
tense,  it  may  be  conducted  while  the  infant  is  nursing  or  feeding,  as 
suggested  by  Fruitnight. 

HEMORRHOIDS 

Hemorrhoids  usually  complicate  cirrhosis  of  the  liver  sooner  or 
later,  but  they  result  also  from  chronic  constipation  and  other  causes. 
The  dietetic  treatment  is  substantially  that  of  chronic  constipation 
(p.  636),  for  much  depends  upon  preventing  the  stools  from  becom- 
ing hard  or  bulky.  Alcohol  is  injurious  especially  in  the  cirrhotic 
cases.  Fresh  fruits  and  abundant  liquids  are  serviceable  in  uncom- 
plicated cases.  Regularity  in  meals  and  in  time  of  going  to  stool 
should  be  enjoined,  with  outdoor  exercise.  Straining  at  stool  should 
be  avoided. 

APPENDICITIS 

Causation. —  Appendicitis  is  mainly  interesting  from  the  dietetic 
standpoint  on  account  of  the  questionable  causative  relation  of  certain 
food  residues.  It  is  a  popular  belief  that  the  disease  is  often  es- 


644  DIET  IN  DISEASES  OF  THE  INTESTINES 

tablished  by  the  presence  in  the  intestine  of  grape  seeds  or  skins, 
lemon,  orange,  or  mustard  seeds,  cherry  pits,  bits  of  chicken  bone  or 
clam  shell,  etc.,  but  such  is  not  the  case.  Substances  of  this  nature 
are  no  doubt  often  swallowed,  but  they  seldom  make  their  way  to 
the  appendix  or  do  any  harm;  and  it  is  now  known  that  the  disease, 
while  it  may  exceptionally  be  produced  by  such  irritants,  is  com- 
monly of  bacterial  origin.  I  have  known  of  one  fatal  case  resulting 
from  eating  a  large  number  of  soft-shell  crabs,  but  such  accidents 
are  very  rare. 

On  the  other  hand  it  is  true  that  both  overeating  and  overdrinking 
may  indirectly  cause  appendicitis  as  well  as  the  consumption  of  too 
highly  seasoned  foods,  for  these  factors  provoke  catarrh  of  the  in- 
testine, distending  the  bowel  with  feces  and  gas,  and  making  it  easy 
for  the  catarrhal  process  or  for  bacteria  of  various  sorts  to  enter 
the  appendix  and  set  up  local  inflammation  there.  The  recurrent 
attacks  are  not  infrequently  precipitated  by  overeating  and  improper 
food. 

The  suggestion  lately  made  by  an  English  writer  that  the 
disease  may  be  due  to  irritation  from  the  iron  consumed  in  an  ex- 
cessive meat  diet,  shows  more  familiarity  with  refinements  of  dietetics 
than  with  the  true  pathology  of  the  disease ! 

Dietetic  Treatment. —  The  dietetic  treatment  of  appendicitis  which 
has  not  yet  passed  into  the  surgeon's  hands  should  consist  in  giving 
only  such  food  as  will  leave  as  little  residue  as  possible  to  irritate  the 
lower  bowel  and  excite  peristalsis.  Until  the  outcome  of  the  attack 
is  decided  it  is  best  to  put  the  patient  upon  a  fluid  diet,  consisting 
chiefly  of  nutritive  broths.  Beaten  eggs  may  be  allowed,  and  a 
moderate  quantity  of  pancreatinized  milk,  beef  juice,  bouillon,  whey, 
or  buttermilk.  Cocoa  may  be  given,  and  strained  gruels  of  rice  or 
barley. 

To  avoid  recurrence  the  patient  should  be  cautioned  to  eat  moder- 
ately and  avoid  all  coarse  or  hard  food,  such  as  grits,  coarse  oatmeal, 
tough  meats,  fibrous  vegetables,  the  skins  of  fruits  or  potatoes  —  in 
short,  everything  likely  to  overload  the  intestine  with  accumulated 
waste,  thus  giving  rise  to  intestinal  catarrh,  which  involves  the  appen- 
dix in  inflammatory  processes. 

The  operative  .cases  should  have  the  diet  recommended  after 
laparotomy  (p.  774).  The  digestive  organs  require  absolute  rest  for 
twenty-four  hours  after  operation,  but  hot  water  may  be  sipped.  No 
food  should  l)e  given  for  some  hours  before  operation,  in  order  that 
the  intestine  may  be  as  empty  as  possible  to  facilitate  manipulation 
of  the  abdominal  contents. 


ACUTE  PEKITONITIS  —  CHRONIC  PERITONITIS         645 

ACUTE  PERITONITIS 

Acute  peritonitis,  if  due  to  causes  within  the  alimentary  canal, 
such  as  a  perforating  ulcer,  demands  absolute  rest  of  the  stomach 
and  intestines,  and  this  is  secured  by  giving  all  nourishment,  stim- 
ulants, and  medicines  in  the  form  of  nutrient  enemata  (p.  455). 
Any  food  in  the  stomach  is  likely  to  excite  vomiting  and  intensify  the 
pain  and  other  symptoms. 

Cases  of  acute  general  peritonitis  demand  immediate  laparotomy, 
and  the  dietetic  treatment  is  given  under  the  heading:  Diet  in 
Surgical  Operations. 

In  localized  cases  not  always  requiring  immediate  operation,  a 
very  little  fluid  nourishment  may  be  administered  cautiously  per  os, 
such  as  pancreatinized  milk,  and  light  gruels  of  pearl  barley  or  arrow- 
root, plain  meat  juice  squeezed  from  a  fresh  steak,  or  one  of  the 
forms  of  pancreatinized  meat  or  egg  albumen  in  sherry  should  be 
tried.  Only  one  or  two  teaspoonfuls  should  be  given  once  in  fifteen 
minutes  or  half  an  hour,  and  every  effort  made  to  prevent  the  oc- 
currence of  vomiting  or  meteorism.  Twelve  or  fifteen  ounces  per 
diem  of  predigested  food  given  by  the  mouth  is  all  that  should  be 
prescribed  in  such  cases.  The  resumption  of  a  full  diet  always  should 
be  very  gradual,  occupying  several  weeks.  The  diet  described  under 
Convalescence  in  Typhoid  Fever  may  be  followed  during  recovery,  as 
detailed  on  page  484. 

It  is  well  to  avoid  the  use  of  aerated  waters  of  all  kinds  on  ac- 
count of  their  tendency  to  increase  meteorism  and  render  the  patient 
still  more  uncomfortable.  Alcoholic  stimulation  may  be  required, 
and  if  the  stomach  is  intolerant  it  should  be  given  in  the  form 
of  dilute  whisky  or  brandy.  The  latter  may  be  added  to  rectal 
enemata. 

CHRONIC  PERITONITIS 

In  chronic  peritonitis  the  outcome  of  chronic  tuberculosis,  or 
other  disease,  plainly  cooked  animal  food  agrees  best.  Starches  and 
sugars,  from  their  tendency  to  ferment  and  dilate  the  bowels  with 
gas,  should  be  avoided.  Broiled  tender  chop,  steak,  chicken,  or  white 
meat  of  fish  may  be  given.  Eggs,  milk,  and  cream  are  permitted 
when  they  do  not  cause  dyspepsia.  Bread  should  be  eaten  sparingly, 
and  always  should  be  stale  or  toasted.  Zwieback  and  crackers  are 
given  for  variety.  All  food  should  be  eaten  very  slowly  and  in  very 
moderate  quantities  at  a  time. 


646  DIET   IN  LIVEB  DISEASES  IN   GENERAL 

DIET  IN  LIVES  DISEASES  IN  GENERAL 

"BILIOUSNESS" 

Symptoms. — "  Biliousness  "  is  an  unscientific  but  very  convenient 
term  employed  to  express  functional  disorder  of  the  liver,  usually 
accompanied  by  an  oversecretion  of  bile,  which  is  often  vomited,  and 
by  overloading  the  system  with  proteid  waste.  The  condition  is  char- 
acterized by  headache,  nausea,  vomiting,  constipation,  a  furred  tongue, 
anorexia,  offensive  breath,  malaise,  and  if  it  continues,  by  a  sallow, 
yellowish,  or  pasty  complexion. 

Causation. —  The  most  common  cause  of  biliousness  is  eating  too 
much  food  or  too  rich  or  badly  cooked  food  combined  with  sedentary 
habits.  (See  Overeating,  p.  411.) 

Sir  Henry  Thompson,  speaking  of  the  habit  of  overeating,  says: 
"  The  surplus  fund  of  nutrient  material  unused  is  stored  up  in  some 
form.  When  a  certain  amount  has  been  thus  disposed  of  —  the  ca- 
pacity for  storage  varying  greatly  in  different  persons  —  an  unde- 
sirable balance  remains  against  the  feeder,  and  in  young  people  is 
mostly  rectified  by  a  'bilious  attack.'  This  relieves  the  system  for 
a  month  or  six  weeks,  when  the  process  may  be  repeated." 

"  In  functional  derangements  of  the  liver  much  more  permanent 
benefit  is  to  be  expected  from  careful  regulation  of  the  ingesta 
than  from  physic"  (Murchison). 

Continued  disregard  of  the  warnings  of  bilious  attacks  is  liable 
to  lead  in  time  to  more  serious  trouble,  such  as  habitual  lithasmia 
or  oxaluria,  and  in  some  cases  gout. 

Persons  spending  a  holiday  at  the  seaside,  who  breathe  more 
invigorating  air  than  that  to  which  they  are  accustomed  in  inland 
cities,  are  tempted  to  eat  too  much  and  exercise  but  little,  with 
the  prompt  result  of  overloading  the  liver  and  inducing  a  bilious 
attack,  for,  as  Harley  says,  the  liver  "  acts  like  a  wise  horse 
when  overloaded  —  simply  stands  still  until  part  of  its  burden  is  re- 
moved." 

Those  who  have  a  tendency  —  often  hereditary  —  to  biliousness 
frequently  exhibit  idiosyncrasies  in  regard  to  special  articles  of  diet, 
the  eating  of  which,  even  in  moderation,  may  quickly  precipitate  an 
attack. 

A  bilious  condition  is  sometimes  induced  by  absorption  of  pto- 
maines from  food  in  the  alimentary  canal,  which  are  taken  up  in 
>uch  quantity  that  the  liver  fails  to  destroy  them.  Bouchard  has  at- 
tempted to  show  that  the  ptomaine-destroying  function  of  the  liver 


"BILIOUSNESS"  647 

is  aided  by  glycogen,  and  is  consequently  favored  by  ingest  ion  of 
starches. 

Dietetic  Treatment. —  The  digestive  functions  of  the  liver  are  so 
varied  that  it  is  difficult  to  arrange  any  diet  for  either  functional 
or  organic  diseases  of  that  organ  which  meets  all  the  requirements 
of  theory,  but  clinical  experience  has  abundantly  proved  the  value  of 
certain  general  principles,  the  most  essential  of  which  is  that  the 
liver  should  be  taxed  as  little  as  possible,  and  a  non-stimulating 
diet  is  required  of  reduced  bulk. 

Food  in  general  after  it  has  reached  the  duodenum  acts  as  a  stim- 
ulant to  the  liver,  and  two  or  three  hours  after  a  full  meal  the 
bile  secretion  is  increased;  but  there  are  a  few  foods  to  which  a 
special  stimulating  effect  has  been  attributed,  although  their  influ- 
ence, if  any,  is  slight.  Condiments,  such  as  pepper,  mustard,  spices, 
and  especially  curry,  may  have  such  effect,  and  should  be  avoided. 
Fats  and  sugars  eaten  too  freely  disturb  the  action  of  the  healthy 
liver,  especially  during  hot  weather. 

Coffee  and  tea  may  be  allowed  only  in  such  moderation  as  one 
cup  a  day.  Beer,  ale,  porter,  strong  liquors,  liqueurs,  and  all 
sweet  wines,  such  as  champagne,  sherry,  Madeira,  port,  and  Tokay, 
are  absolutely  forbidden.  Alcohol  should  be  prohibited  as  a  rule,  but 
if  necessary,  a  little  Rhine  wine,  hock,  or  Moselle  may  be  used  (not 
over  a  couple  of  glasses  daily),  or  much-diluted  whisky.  Of  all  the 
organs  of  the  body,  none  is  more  often  poisoned  and  made  cirrhotic 
b}r  alcohol  than  the  liver,  and  the  moral  needs  no  further  emphasis. 
Many  medicines,  such  as  opium,  derange  the  liver  functions  and  inter- 
fere with  the  elaboration  of  food. 

More  or  less  intestinal  dyspepsia  always  results  from  alterations 
in  the  quantity  or  composition  of  the  bile,  and  on  this  account  as  well, 
the  food  should  be  selected  carefully,  and  all  sugars  and  most  farina- 
ceous aliments  forbidden  as  well  as  fats. 

Among  the  articles  especially  prohibited  in  all  cases  of  liver  dis- 
ease are  condiments,  spices,  curries,  pickles,  sauces,  rich  soups,  fried 
food  of  every  kind,  veal,  pork,  sausages;  salt  foods,  such  as  corned 
beef  and  salt  fish ;  crustaceans,  new  bread,  preserves,  and  sweets  of 
all  sorts;  pastry,  puddings,  cakes;  all  the  heavier  starchy  vegetables, 
such  as  potatoes,  corn,  peas,  beans,  beets;  salad  oil,  oily  fish,  like 
salmon  and  sardines.  Only  fresh  food  should  be  given. 

In  acute  functional  derangement  of  the  liver,  at  first,  if  there  are 
vomiting  and  headache,  only  light  gruels,  and  perhaps  dry  toast  or 
crackers  should  be  eaten. 

In  regard  to  the  suggestions  given  below,  it  may  be  stated  that 


648  DIET  IN  LIVER  DISEASES  IN   GENERAL 

they  are  very  general,  and  are  applicable  rather  to  the  chronic  types 
of  hepatic  disease,  although  they  will  serve  also  for  those  afflicted 
with  recurrent  or  intermittent  attacks  of  biliousness,  and  should  be 
followed  between  the  attacks.  In  very  active  disease,  such  as  acute 
congestion,  acute  yellow  atrophy,  abscess  of  the  liver,  etc.,  obviously 
the  diet  should  be  limited  much  more.  In  ordinary  uncomplicated 
bilious  attacks  induced  by  high  living,  a  day  or  two  of  practical 
starvation  with  the  use  of  a  mercurial  cathartic,  is  curative. 

The  following  articles  usually  may  be  allowed  in  moderation  ex- 
cepting in  very  serious  cases: 

Animal  Food. —  Fish,  such  as  sole,  flounder,  halibut,  smelt,  white- 
fish;  the  soft  part  of  oysters,  sweetbread;  lean  meat,  such  as  rare 
roast  beef,  broiled  beefsteak,  mutton  chops,  or  chicken  (lean  beef 
is  better  than  game)  ;  eggs,  milk  preparations,  such  as  koumiss,  whey, 
buttermilk,  junket,  malted  milk.  Many  persons  with  hepatic  disorder 
insist  that  pure  milk  always  makes  them  bilious.  If  this  proves  to 
be  true  of  natural  milk,  it  should  be  predigested  or  given  with  sodium 
bicarbonate  or  Vichy,  or  in  one  of  the  numerous  ways  described  on 
p.  90.  All  meats  and  eggs  should  be  allowed  only  in  great  moderation. 

In  advanced  cases  of  hepatic  disease  milk  constitutes  an  excellent 
food,  and  may  be  used  abundantly,  provided  the  proper  form  for  its 
administration  in  a  given  case  is  determined.  Baked  custard  and 
blancmange  or  other  forms  of  gelatin  may  be  eaten. 

Vegetable  Food. —  Of  fresh  green  vegetables  the  following  may  be 
eaten:  Spinach,  string  beans,  asparagus,  tomatoes,  squash,  celery, 
oyster  plant,  beet  tops,  cresses,  lettuce  (without  oil).  Potatoes, 
mashed  or  baked  may  be  eaten. 

Cereals, —  Bread  should  be  eaten  in  small  amount,  stale  or  toasted. 
Zwieback  is  good,  and  dry  rusk,  not  too  sweet.  Graham,  gluten,  or 
wheaten  crackers  may  be  permitted.  Other  starchy  foods  should 
be  taken  sparingly;  but  boiled  rice,  rice  puddings,  sago,  and  tapioca 
are  admissible  occasionally. 

Fruits. —  Fresh  fruit  in  season  is  wholesome,  and  useful  to  over- 
come the  tendency  to  constipation.  Grapes,  oranges,  pineapple  juice, 
plums,  peaches,  and  roast  apples  may  be  eaten. 

"Water  should  be  drunk  freely,  except  when  ascites  is  present;  and 
light  beverages,  such  as  lime  juice  in  aerated  water,  lemonade,  or 
orangeade  vinegar,  may  be  serviceable. 

Directions  for  Eating. —  The  manner  of  taking  food  is  important. 
There  is  hypersemia  of  the  stomach  and  intestines  from  time  to  time, 
as  a  result  of  engorgement  of  the  portal  system,  and  catarrhal  condi- 
tions are  easily  excited  in  these  organs  by  food  which  is  hastily  bolted 


CATARKHAL  JAUNDICE  649 

without  thorough  mastication  or  which  is  not  well  cooked  or  not 
perfectly  fresh.  The  teeth  should  be  examined  to  ascertain  if  the 
patient  can  masticate  properly.  Fluids  should  not  be  drunk  with 
meals.  The  patient  should  not  eat  directly  after  violent  exercise  or 
fatigue,  but  should  first  lie  down  and  rest  for  three-quarters  of  an 
hour.  If  he  suffers  from  dyspepsia,  he  should  rest  after  meals  as 
well.  In  many  cases  three  meals  a  day  suffice,  and  should  be  given 
at  intervals  of  five  hours,  to  insure  complete  digestion  between.  In 
others,  when  the  patient  is  considerably  enfeebled,  or  in  cases  of 
hepatic  congestion  and  advanced  cirrhosis,  it  is  better  to  order  meals 
four  or  five  times  a  day,  or  once  in  three  hours,  giving  a  smaller 
quantity  of  food  which  is  readily  digested.  It  is  advisable  to  take  the 
principal  meal  at  noon. 

Constipation  is  the  rule,  and  laxatives  should  be  prescribed  fre- 
quently if  the  bowels  cannot  be  kept  in  order  by  fresh  fruit. 

Hot  water  in  an  empty  stomach  is  quickly  absorbed,  and  passes 
directly  to  the  liver  through  the  portal  vessels.  If  salts,  such  as 
Carlsbad  salt,  are  given,  they  are  absorbed  with  the  water,  and  pos- 
sibly stimulate  the  liver  cells.  The  water  increases  the  portal  blood 
pressure,  and  thus  indirectly  the  pressure  of  the  gall  ducts,  promotes 
elimination  of  bile,  and  dilutes  toxins. 

Moderate  systematic  exercise  should  be  prescribed  whenever  pos- 
sible, and  the  best  forms  are  horseback  and  bicycle  riding.  The 
"  jouncing  "  movements  of  the  former  shake  and  compress  the  liver, 
and  stimulate  its  circulation  and  the  elimination  of  bile. 

ACUTE  CATARRHAL  INFLAMMATION  OF  THE 

BILE  DUCTS  — ANGIOCHOLITIS  — 

CATARRHAL  JAUNDICE 

A  bland  or  non-stimulating  diet  is  appropriate  for  the  acute  stage 
of  angiocholitis.  Vomiting  is  sometimes  present,  so  that  the  stomach 
is  not  in  a  condition  to  bear  solid  food.  Moreover,  too  much  food  on 
entering  the  duodenum  will  increase  the  local  inflammation  of  the 
common  bile  duct.  Diluted  or  peptonized  milk  is  to  be  given,  or 
buttermilk,  whey,  light  meat  broths,  clam  broth,  pressed-beef  juice, 
egg  albumen. 

In  a  few  days,  if  pain,  tenderness,  vomiting,  and  fever  subside,  the 
diet  is  to  be  increased  slowly,  and  such  articles  may  be  added  as  milk 
toast,  bread  and  milk,  broths  and  light  soups  without  vegetables,  the 
breast  of  chicken,  oysters,  sweetbread,  meat  jellies.  Later,  eggs,  and 
boiled  or  broiled  fresh  steak  may  be  eaten.  Fat  and  butter  should 
44 


650  DIET   IN   LIVER  DISEASES  IN   GENERAL 

be  avoided,  for  occlusion  of  the  crystic  duct  lessens  fat  absorption  by 
withholding  bile  from  the  intestine,  and  pains  should  be  taken  to 
prevent  constipation  and  putrescence  of  the  intestinal  contents. 

Fatty,  amylaceous,  and  saccharine  food  is  forbidden,  and  for  some 
time  after  the  acute  symptoms  have  subsided  the  basis  of  diet  should 
be  fish,  lean  meats,  and  fresh  green  vegetables. 

Cooked  fruits,  not  too  sweet,  and  to  which  sugar  has  not  been 
added,  such  as  sour  apples,  prunes,  etc.,  may  be  eaten.  Considerable 
fluid  should  be  taken  both  as  a  diluent  and  to  promote  the  action  of 
the  kidneys  and  lessen  the  tendency  to  constipation.  Water  acidu- 
lated with  lemon  juice  or  effervescent  waters  (soda  water,  Seltzer, 
and  Apollinaris)  may  be  drunk  three  or  four  times  a  day  between 
meals.  Coffee  and  tea  are  permissible  only  during  convalescence. 

CIRRHOSIS  —  ASCITES 

Causation. —  Cirrhosis  is  a  disease  of  the  liver  occasioned  by  irrita- 
tion of  that  organ  .by  substances  in  the  blood  derived  among  other 
sources  from  the  portal  system  after  direct  absorption  from  the  in- 
testine. Among  such  irritants  may  be  mentioned  as  the  foremost 
excitant,  alcohol,  which  produces  fully  60  per  cent  of  all  cases. 
Strong  alcoholic  stimulants  often  contain  fusel  oil  or  other  especially 
noxious  impurities.  The  prolonged  excessive  use  of  strong  condi- 
ments, or  spices,  such  as  curry  and  peppers,  may  contribute  to,  if 
they  do  not  directly  cause  cirrhosis.  Experimentally,  ptomaines  have 
been  made  to  excite  the  disease  in  the  lower  animals,  and  continued 
poisoning  by  such  agents  may  possibly  contribute  to  it  in  man. 
Cirrhosis  may  be  caused  in  other  ways,  but  the  facts  above  mentioned 
show  its  possible  relation  to  dietetic  errors.  As  a  result  of  fibrous 
hepatitis,  the  terminals  of  the  portal  vein  are  obstructed  and  the 
portal  venous  system  is  congested,  the  blood  being  dammed  back  in 
the  vessels  of  the  stomach,  spleen,  intestines,  and  pancreas.  Owing 
to  the  congestion  there  is  frequent  vomiting,  sometimes  of  blood,  and 
there  is  marked  interference  with  the  character  of  the  digestive  se- 
cretions as  well  as  the  process  of  intestinal  absorption. 

Dietetic  Treatment  of  Cirrhosis  without  Ascites. —  Cirrhosis  with- 
out accompanying  ascites  is  often  best  treated  by  a  milk  diet  for  two 
or  three  weeks.  Bread  and  crackers  may  be  allowed  with  the  milk, 
but  nothing  else.  Hot  water  and  aerated  waters  should  be  drunk 
in  large  quantities,  fasting,  to  "  flush  "  the  system.  Subsequently  a 
light  diet  is  to  be  prescribed  in  accordance  with  the  suggestions  given 
for  tin.-  Treatment  of  liver  diseases  in  general  (p.  647).  All  condi- 


CIRRHOSIS  —  ASCITES  651 

ments,  relishes,  sauces,  fats,  fried  food,  pastry,  and  sweets  should 
be  withheld,  as  well  as  alcohol  in  every  form.  The  skin  and  bowels 
should  be  kept  active. 

Ascites 

Pathological  Physiology. —  A  further  important  symptom  which  is 
often  observed  toward  the  close  of  a  protracted  cirrhosis,  is  ascites, 
or  accumulation  of  serum  in  the  peritoneal  cavity,  which  has  been 
produced  by  the  altered  blood  pressure  of  the  portal  system  and 
the  altered  composition  of  the  blood  itself.  The  fluid  accumulates 
with  considerable  rapidity,  and  may  reach  an  enormous  quantity  — 
sometimes  as  much  as  twenty-four  quarts  —  greatly  distending  the 
abdominal  walls,  floating  the  viscera  out  of  position,  and  by  pressure 
interfering  with  digestion  and  absorption.  In  addition  the  loss  of 
so  large  a  quantity  of  serum  from  the  blood  is  a  serious  detriment 
to  nutrition,  inasmuch  as  the  ascitic  fluid  not  only  contains  water  in 
large  quantity,  but  serum  albumin,  which  may  be  present  in  the 
proportion  of  from  1  to  over  6  per  cent.  In  the  ascites  accompanying 
cirrhosis  the  loss  of  albumin  in  this  manner  may  be  somewhat  less 
than  when  the  serous  accumulation  is  due  to  other  causes. 

Repeated  aspiration  of  the  abdominal  cavity  not  only  abstracts  large 
quantities  of  water  from  the  system,  but  also  abstracts  considerable 
protein.  In  those  cases  in  which  fluid  refills  the  peritoneal  cavity 
promptly  after  aspiration,  it  is  a  question  whether  the  nutrition  of 
the  body  may  not  suffer  by  drawing  off  so  much  serum  albumin. 
On  the  other  hand,  when  once  transuded,  it  is  of  no  further  service  to 
the  organism  unless  it  can  be  reabsorbed.  The  point  for  considera- 
tion is  whether  too  frequent  removal  of  the  ascitic  fluid  will  cause 
greater  drain  on  the  blood  than  would  be  consequent  upon  letting  it 
accumulate  in  the  abdominal  cavity.  Much  will  depend  upon  the 
relative  pressure  within  the  peritoneal  sac  and  the  bloodvessels,  which 
will  affect  the  rate  of  osmosis  of  albumin.  This  discussion  leads  to 
the  queries,  first,  whether  it  is  not  necessary  to  supply  the  constant 
loss  of  albumin  by  an  increased  allowance  of  animal  food,  and, 
secondly,  to  what  extent  water  should  be  withheld  from  the  dietary. 

Dietetic  Treatment  of  Cirrhosis  with  Ascites. —  When  uncomplicated 
ascites  is  present  it  is  generally  best  to  restrict  the  quantity  of  fluid 
ingested  and  put  the  patient  upon  a  "  dry  diet,"  consisting  of  stale 
bread  and  butter,  and  meat  chiefly.  By  simply  withholding  liquid 
and  stimulating  the  force  of  the  heart  and  the  action  of  the  kidneys 
I  have  sometimes  seen  diminution  in  the  abdominal  fluid,  but  this 
treatment  is  not  always  successful.  There  is  more  hope  of  success 


652  DIET  IN   LIVER  DISEASES  IN   GENERAL 

when  the  disease  occurs,  as  it  rarely  does,  in  young  persons.  Cirrhosis 
and  ascites  are  very  apt  to  be  associated  with  renal  and  cardiac  lesions 
and  gastric  catarrh,  which  make  it  much  easier  to  say  what  food 
the  patient  must  not  eat  than  what  he  may  have.  If  the  urine  is  very 
scanty  it  may  not  be  wise  to  withhold  fluids,  and  some  clinicians 
of  wide  experience  believe  in  giving  liquids  in  unrestricted  quantity, 
holding  the  view  that  this  will  increase  diuresis  to  such  an  extent 
that  not  only  will  all  the  fluid  drunk  be  eliminated  promptly,  but 
that  the  active  kidneys  will  drain  more  from  the  blood,  which  will 
in  time  be  replaced  by  reabsorption  of  the  ascitic  fluid.  The  same 
reasoning  is  applicable  in  cases  of  pleurisy,  general  anasarca,  etc. 
It  seems  more  rational  to  endeavor  to  promote  diuresis  when 
possible  by  medicinal  measures  than  to  add  a  large  bulk  of  fluid  to 
an  already  overbalanced  circulation.  If  the  fluid  diet  is  followed  by 
rapid  reaccumulation  of  ascitic  fluid  after  aspiration,  for  example, 
within  a  fortnight,  it  is  desirable  to  replace  it  by  as  much  simple 
solid  nutriment  as  the  patient  can  digest,  or  by  predigested  and  con- 
centrated foods.  An  outline  of  the  appropriate  diet  for  such  cases 
is  given  upon  p.  592. 

The  "  salt-free  "  diet  recommended  for  pleurisy  with  effusion,  on 
page  556,  may  prove  advantageous. 

It  is  of  importance  in  every  case  to  measure  and  estimate  care- 
fully the  total  quantity  of  liquid  ingested  both  in  beverages  and  as 
food  and  make  a  comparison  with  the  quantity  of  urine  voided,  and 
if  possible  with  the  weight  of  the  patient  and  girth  of  the  abdomen 
at  different  levels. 

The  "  grape  cure "  and  "  milk  cure "  have  been  strongly  recom- 
mended in  Europe  for  the  treatment  of  cirrhosis  and  ascites.  They 
are  said  to  ameliorate  the  symptoms  and  promote  reparative  processes, 
both  acting  largely  through  diuretic  influence. 

FATTY  LIVER 

Pathological  Physiology. —  The  liver  is  the  great  storehouse  of 
latent  energy  in  the  body,  which  is  accumulated  in  glycogen  and 
fat.  A  certain  proportion  of  fat  is  to  be  regarded  as  a  normal  con- 
stituent of  the  parenchyma  of  the  liver.  This  varies  with  the  char- 
acter of  the  food  ingested  and  degree  of  its  oxidation  in  the  liver 
and  other  tissues.  After  a  diet  consisting  largely  of  fats  and  oils  or 
of  carbohydrates  the  accumulation  of  fat  in  the  liver  is  considerable. 
Lack  of  exercise  and  unfavorable  hygienic  conditions,  by  retarding 
oxidation  processes,  also  promote  its  accumulation.  Persons  addicted 


FATTY  LIVER  653 

to  constant  overeating  of  carbohydrates  are  therefore  liable  to  this 
affection.  They  become  stout,  take  less  and  less  exercise,  and  the 
second  condition  favoring  fatty  infiltration  of  the  liver  —  namely, 
lack  of  oxidation  —  is  added.  Fatty  degeneration  of  the  liver  is 
caused  by  various  diseases  in  which  the  composition  of  the  blood  is 
altered  and  the  metabolism  of  oxidation  is  interfered  with.  Such  are 
advanced  anaemia,  chronic  alcoholism,  and  tuberculosis.  It  is  sug- 
gested by  R.  H.  Fitz  that  the  fatty  diet  often  recommended  for  the 
latter  disease  —  consisting  of  cod-liver  oil,  rich  milk,  butter,  cream, 
etc. —  may  be  productive  of  fatty  disease  of  the  liver. 

Dietetic  Treatment. —  The  dietetic  treatment  is  indicated  by  the 
previous  considerations,  but  since  the  local  condition  is  commonly 
merely  an  accompaniment  of  more  serious  general  disease,  it  may  be 
unwise  to  advise  too  sudden  or  extreme  alterations  in  the  accustomed 
diet  of  the  patient.  In  general,  all  forms  of  sugar,  starch,  and  fat 
should  be  reduced  gradually  to  a  minimum,  excepting  in  tuberculous 
patients  whose  general  bodily  nutrition  is  of  more  importance  than 
the  danger  of  local  fatty  infiltration.  In  these  cases  the  object  de- 
sired is  better  promoted  by  increasing  oxidation  processes  by  climatic 
and  hygienic  treatment  rather  than  by  withholding  carbohydrates. 
Malt  liquors  and  alcoholic  drinks  in  general  are  forbidden.  In  other 
cases,  especially  in  the  alcoholic  form,  the  diet  should  consist  of 
proteid  food,  fresh  green  vegetables,  and  fresh  succulent  fruits. 

SUMMARY  OF  DIET  FOR  FATTY  LIVER 

Meats:  Beefsteak,  rare  roast  beef,  lean  mutton,  roast  lamb,  chops, 
veal,  chicken,  capon,  turkey,  squab,  sweetbread. 

Fish:  Fresh  fish,  boiled  or  broiled,  of  any  sort  except  salmon, 
mackerel  and  bluefish  (as  containing  too  much  fat). 

Vegetables:  White  potatoes  (very  sparingly)  string  beans,  lettuce, 
cauliflower,  spinach,  celery,  tomatoes,  artichokes,  squash,  parsnips, 
onions,  eggplant,  oyster  plant. 

Cereals:  Dry  toast,  crackers,  Huntley  and  Palmer  wafers.  Gra- 
ham bread  and  oatmeal  in  small  quantity. 

Fruits:  Oranges,  grape  fruit,  peaches,  pears,  plums,  prunes,  figs, 
apples  (raw  or  cooked),  melons. 

Beverages:  Weak  tea  or  coffee  with  saccharin  in  lieu  of  sugar. 
Alkaline  effervescing  waters.  Lemonade,  orangeade. 

Foods  Especially  Forbidden  Are:  Butter,  cream,  eggs,  fried  foods 
of  every  sort,  bacon,  ham,  pork,  sausage,  pickles,  condiments,  pastry, 
confectionery,  preserves,  sirup,  puddings,  desserts  of  all  kinds  ex- 
cept simple  gelatin  foods  (p.  147). 


654  DIET   IN  LIVER  DISEASES  IN   GENERAL 

AMYLOID  LIVER 

The  condition  of  amyloid  liver  after  it  has  become  sufficiently 
pronounced  for  diagnosis  is  usually  fatal  within  a  short  period,  and 
consequently  little  aid  can  be  derived  from  dietetic  treatment.  The 
diet  should  be  so  regulated  as  to  burden  the  digestive  organs  as 
little  as  possible,  and  in  advanced  cases  such  predigested  foods  as 
peptonized  meat  or  milk  ought"  to  be  given.  If  the  stomach  diges- 
tion is  fairly  active,  proteids  will  agree  better  than  the  carbohydrates. 

SYPHILIS  OF  THE  LIVER 

In  advanced  syphilitic  hepatic  disease  very  simple  food  only  is 
permissible,  such,  for  example,  as  milk  and  eggs,  chicken,  beef  or 
mutton  broths,  fresh  fish,  oatmeal,  boiled  rice,  toast  or  stale  bread, 
and  light  farinaceous  puddings  —  such  as  tapioca,  sago,  blancmange, 
and  custards.  Alcohol  in  all  forms  is  prohibited. 

ABSCESS  OF  THE  LIVER 

In  hepatic  abscess  the  same  dietetic  treatment  is  to  be  followed  as 
that  indicated  for  syphilitic  disease  of  the  liver.  The  aim  should  be 
to  avoid  overloading  the  digestive  organs  at  any  time,  and  to  give 
assimilable  and  predigested  food  in  small  quantities  at  frequent  inter- 
vals. Animal  broths  and  light  vegetable  purees,  with  various  com- 
binations of  milk  and  eggs,  should  form  the  staple  articles.  No  solid 
food  should  be  given,  except  perhaps,  a  little  fresh  fish,  such  as  sole 
or  whitefish,  a  few  oysters,  sweetbread,  and  milk  toast. 

Fats  in  all  forms  are  forbidden.  Malt  liquors,  port,  sherry,  and 
all  varieties  of  strong  alcoholic  drinks  are  prohibited. 

GALLSTONES 

Pathological  Physiology. —  Gallstones  are  formed  in  the  gall  blad- 
der or  larger  bile  ducts  by  precipitation  from  the  bile  of  cholesterin, 
mixed  with  more  or  less  mucus  and  often  a  bacterial  nucleus.  Oc- 
casionally they  contain  bile  pigment  (bilirubin)  or  calcium  carbonate. 
Cholesterin  is  an  alcoholic  substance  which  may  be  extracted  in  vary- 
ing amount  from  the  blood  or  nervous  tissues,  especially  the  brain, 
and  from  the  bile.  It  may  be  obtained  in  flat,  rhombic,  colorless  crys- 
tals. Somewhat  rarely  it  is  excreted  in  the  urine.  It  also  exists  in  the 
waste  matter  contained  in  the  lower  bowel.  It  is  maintained  in  solu- 


GALLSTONES  655 

tion  in  the  bile  by  alkaline  salts,  the  sodium  and  potassium  taurocho- 
late  and  glycocholate.  Calcium  unites  with  the  latter  substances, 
forming  new  compounds  with  the  biliary  acids  which  are  insoluble 
salts  that  no  longer  hold  cholesterin  in  solution.  When  organic  acids 
exist  in  excess  in  the  tissues  calcium  is  liberated,  and  on  reaching 
the  liver  produces  the  above  reaction. 

An  excessive  accumulation  of  cholesterin  in  the  system  will  result 
in  its  precipitation  from  the  bile,  and  this  occurs  when  for  any  rea- 
son the  bile  has  long  been  retained  in  the  gall  bladder,  where  it  has 
been  concentrated  by  reabsorption  of  some  of  its  fluid  ingredients. 
Bacteria  are  undoubted  agents  in  the  formation  of  many  stones.  The 
precipitation  of  cholesterin  is  favored  by  the  presence  of  a  pre-existing 
hepatic  stone  or  any  foreign  body  in  the  gall  bladder,  such  as  an  intes- 
tinal parasite,  or  its  ovum,  or  thickened  mucus  or  a  group  of  bacteria. 

Gallstones  are  oftenest  present  in  advanced  life  and  among  those 
who  adopt  sedentary  habits  which  lead  to  accumulation  of  bile  in  the 
gall  bladder.  On  the  latter  account  they  are  more  common  among 
females,  and  their  occurrence  may  be  related  to  excesses  of  the  table, 
in  regard  to  both  food  and  drink. 

All  diseases  of  nutrition,  such  as  long-continued  dyspepsia,  chronic 
rheumatism  and  gout,  diabetes,  and  obesity,  may  be  accompanied  by 
the  formation  of  biliary  calculi. 

Among  other  explanations  given  for  the  formation  of  gallstones 
is  an  excessive  proportion  of  fat  in  the  diet,  although  cholesterin  is 
not  true  fat,  but  an  alcohol  allied  to  fats  in  some  of  its  properties. 
Lack  of  exercise  is  a  strong  contributing  factor. 

Harley,  who  has  given  more  careful  attention  than  any  other  writer 
to  the  prevention  of  a  return  of  gallstones  by  dietetic  treatment,  called 
attention  to  their  greater  prevalence  in  cold  latitudes  than  elsewhere, 
and  attributed  this  fact  to  the  influence  of  certain  foods,  especially 
meat,  fat  and  suet.  He  wrote :  "  Starchy  puddings  and  fat  bacon 
cause  more  gallstones  in  this  country  [England],  I  believe,  than  all 
the  other  kinds  of  food  put  together." 

The  hydrocarbons  are  more  completely  consumed  in  early  years 
than  after  middle  life,  and  hence  the  greater  prevalence  of  gallstones 
in  the  latter  period,  as  above  mentioned. 

Bauer  believes  that  "the  formation  of  gallstones  may  often  be 
referred  to  a  faulty  diet,  for  an  excessive  consumption  of  meat  or 
free  indulgence  in  fat  and  in  spirits  would  probably  favor  their 
formation." 

In  many  cases  the  stones  exist  in  considerable  number  and  size 
without  giving  rise  to  any  symptoms  or  discomfort,  but  the  smaller- 


656  DIET   IN  LIVER  DISEASES  IN   GENERAL 

sized  stones  occasionally  find  their  way  into  the  common  bile  duct, 
and  their  passage  provokes  intense  agonizing  local  pain,  known  as 
biliary  .colic. 

Dietetic  Treatment. —  From  the  above  account  of  the  manner  of 
formation  of  bile  stones  it  is  evident  that  patients  who  have  once 
suffered  from  biliary  colic  or  other  symptoms  of  the  presence  of  con- 
cretions should  exercise  care  in  their  diet  and  habits  of  life,  in  order 
to  prevent  the  further  formation  of  stones,  although  it  is  probably 
impossible  to  dissolve  those  already  present.  The  diet  should  be  regu- 
lated with  the  object  of  lessening  the  production  of  cholesterin  and 
of  diluting  the  bile.  Animal  food  may  contain  cholesterin,  and  should 
therefore  be  taken  very  sparingly.  A  diet  of  concentrated  animal 
food,  by  diminishing  the  alkalinity  of  the  fluids  of  the  body,  favors 
the  deposition  of  cholesterin  from  the  bile,  although  this  ingredient 
may  not  be  present  in  abnormal  amount  in  such  food.  Patients  should 
be  cautioned  against  excessive  indulgence  in  any  particular  article  of 
food,  all  richly  cooked  food  should  be  given  up,  and  if  they  are  in  the 
habit  of  eating  proteids  in  excess,  a  larger  proportion  of  fresh  vegeta- 
bles or  farinaceous  food  should  be  substituted. 

Calves'  brains  and  the  viscera  of  animals  used  as  food  in  general, 
and  particularly  the  liver,  should  be  interdicted.  Sugars  and  fats 
should  be  forbidden  in  every  variety.  Butter  and  cream  should  be 
omitted  also  from  the  dietary. 

Some  vegetables,  such  as  peas  and  carrots,  are  believed  to  contain 
material  which  closely  resembles  cholesterin.  Carrots,  moreover,  are 
sweet,  and  sweet  vegetables  and  fruits  should  be  avoided,  and  also  egg 
yolks,  on  account  of  the  fat  they  contain. 

Fresh  green  vegetables  and  acid  fruits  which,  by  virtue  of  their 
alkaline  salts  and  organic  acids,  easily  combine  in  the  blood  with 
alkaline  bases  should  make  the  basis  of  the  diet.  The  potassium 
salts  which  are  contained  in  potatoes  and  other  vegetables  in  abun- 
dant quantity  are  believed  to  be  serviceable,  because  they  retard  the 
liberation  of  calcium,  which,  it  has  been  shown,  precipitates  choles- 
terin. Bread  and  well-cooked  cereals  and  fresh  fish,  except  salmon, 
bluefish,  and  mackerel,  may  be  eaten.  Chicken  or  lean  beef  may  be 
allowed,  but  all  meat  should  be  taken  sparingly  and  not  oftener  than 
once  a  clay. 

For  the  purpose  of  diluting  the  blood  and,  through  it,  the  bile, 
large  quantities  of  fluid  should  be  ingested,  but  it  is  best  to  avoid 
ai'-rated  waters  and  mineral  waters  which  contain  salts  of  lime.  A 
tumblerful  of  hot  water  should  be  drunk  at  night,  and  another  on 
rising  in  the  morning.  Champagne  and  other  beverages  which  hold 


DIET  IN  PANCREATIC  DISEASES  657 

much  carbonic-acid  gas  in  solution  should  be  avoided,  as  well  as  malt 
liquors.  Coffee,  tea,  and  claret  may  be  drunk  in  moderation.  If 
the  case  is  one  in  which  considerable  gastric  catarrh  or  dilatation  of 
the  stomach  is  present,  it  is  inadvisable  to  give  much  fluid  by  the 
mouth,  and  sometimes  the  desired  result  may  be  obtained  by  inject- 
ing salt  water  through  a  long  flexible  rubber  tube  into  the  colon. 
Intestinal  irrigation  as  well  as  active  purgation  favors  removal  of  the 
bile  and  prevents  its  accumulation  in  the  gall  bladder.  It  is  well  to 
give  one  or  two  drachms  of  sodium  phosphate  or  sulphate  daily  to  pre- 
vent concentration  of  the  bile.  For  occasional  purgation  the  Carlsbad 
Sprudel  salts  and  Saratoga  water  salts  are  valuable.  In  women  tight 
lacing  should  be  prevented,  and  the  habit  of  sitting  long  in  cramped 
positions  which  interfere  with  free  hepatic  circulation. 

Although  dietetic  treatment  for  prevention  of  a  return  of  at- 
tacks of  gallstone  colic  should  be  undertaken  as  described  above,  it  is 
by  no  means  always  successful,  and  recent  knowledge  of  the  bacterial 
origin  of  gallstones  has  discredited  to  some  extent  previous  theories 
of  their  dietetic  origin.  Many  cases  require  operative  relief. 

Large  doses  of  olive  oil,  several  ounces  at  a  time,  have  been  recom- 
mended for  use  during  the  passage  of  a  gallstone,  with  the  idea  appar- 
ently of  in  some  mysterious  way  lubricating  the  channels  through 
which  the  stone  is  carried.  But  the  oil,  if  absorbed,  is  taken  up  by 
the  lacteals  and  emptied  into  the  thoracic  4uct  without  going  any- 
where near  the  liver  or  bile  passages,  so  that  such  an  explanation  of  its 
use  is  absurd.  The  foreign  bodies  which  it  is  claimed  appear  in  the 
stools  after  giving  oil  in  this  manner  have  proved  to  be  not  stones,  but 
inspissated  masses  of  oil. 


Disease  of  the  pancreas  is  usually  difficult  to  diagnose  with  ac- 
curacy until  far  advanced,  and  little  may  be  expected  from  dietetic 
treatment.  Whereas  the  pancreatic  juice  is  the  most  important  of  all 
the  digestive  fluids,  being  a  universal  digestive  agent  for  all  foods,  and 
the  most  active  one,  its  absence  or  deterioration  results  promptly  in 
emaciation,  which  becomes  extreme.  When  the  presence  of  disease  of 
this  gland,  such  as  a  cyst,  is  established,  it  is  best  to  withhold  all  fats 
and  carbohydrates  from  the  diet.  They  are  not  digested  in  the  stom- 
ach, and  when  the  pancreatic  juice  fails,  they  merely  ferment  in  the 
small  intestine  and  do  positive  harm.  Milk,  pancreatinized  meat 
preparations,  beef  peptonoids,  and  egg  albumen  constitute  the  chief 
reliance  for  nourishment. 


658 

It  is  of  interest  to  note  that  the  continued  presence  of  fat  or  oil  in 
stools  after  ingestion  of  large  amounts,  is  regarded  as  a  strong  diag- 
nostic point  in  favor  of  the  absence  of  pancreatic  juice.  As  a  positive 
test  this  may  have  some  value,  but  not  as  a  negative  one,  for  if  bile  be 
present  in  normal  quantity  the  fat  of  food  may  still  be  emulsified  and, 
to  some  extent,  absorbed.  In  a  half  dozen  cases  of  undoubted  pan- 
creatic cyst  in  which  the  diagnosis  was  established  by  aspiration  or 
autopsy,  I  have  known  doses  of  several  ounces  of  olive  oil  administered 
for  diagnostic  purpose  to  give  no  residue  in  the  stools.  The  absence 
of  fat  in  the  feces  does  not  therefore  necessarily  exclude  pancreatic 
disease.  Pentose  may  appear  in  the  urine.  (Cammidge). 

DIET   IN  DISEASES   OF   THE   NEKVOUS   SYSTEM 

NEURALGIA  —  GASTRALGIA  —  ENTERALGIA 

Causation. —  Neuralgia  is  a  term  applied  to  a  variety  of  nerve 
pains  which  may  be  associated  with  organic  lesions  of  various  struc- 
tures which  irritate  the  peripheral  nerves,  or  which  may  be  purely 
functional  and  temporary  excitations  of  the  nerve  trunks  or  their  end 
organs.  Lesions  involving  the  nerves  themselves  are  not  described 
as  neuralgias.  The  proper  functioning  of  nerve  fibers  is  so  dependent 
upon  nutrition  that  debility  resulting  from  imprudent  living  and  im- 
proper or  insufficient  food  naturally  ranks  among  the  chief  predis- 
posing causes  of  this  affection. 

Persons  undergoing  severe  mental  worry  or  strain,  physical  fatigue, 
prolonged  exposure  to  cold,  prolonged  lactation,  etc.,  may  suffer  from 
indigestion  or  mal-assimilation  of  their  food,  and  the  one  condition 
reacts  upon  the  other  in  altering  the  tone  of  the  nervous  system. 

Moreover,  many  diseases  which  may  be  called  dietetic  in  that  they 
are  closely  associated  with  or  influenced  by  dietetic  errors  (acting 
eventually  through  the  composition  of  the  blood)  are  very  commonly 
accompanied  by  neuralgic  pains.  Such  are  gout,  rheumatism, 
lithremia,  arthritis  deformans,  diabetes,  and  chronic  alcoholism.  To 
benefit  the  diseased  condition  by  appropriate  diet,  among  other  means, 
is  to  cure  the  neuralgia. 

Neuralgic  pains  are  often  connected  immediately  with  the  digestive 
tract,  especially  in  cases  of  neurasthenia  and  hysteria  among  women, 
and  are  excited  by  irritating  foods  or  fermentative  processes.  They 
are  particularly  caused  by  intestinal  autointoxication,  (p.  621.) 

Dietetic  Treatment. —  The  dietetic  treatment  of  neuralgia  is  based 
upon  general  principles  which  may  be  observed  wherever  they  do  not 


NEURALGIA  659 

conflict  with  the  special  disease  of  which  the  pain  may  be  merely  an 
incidental  symptom.  This  treatment  is  liable  to  be  overlooked  while 
attention  is  directed  to  devising  new  remedies  for  the  immediate, 
though  often  merely  temporary,  relief  of  the  pain. 

It  is  essential  to  ascertain  the  cause  of  the  pain  and  learn  whether 
it  be  not  due  to  one  of  the  conditions  above  mentioned,  which 
may  be  found  to  exist  in  a  latent  form.  Examination  of  the  urine 
should  be  made  in  all  cases  to  ascertain  the  possible  presence  of  the 
uric-acid  diathesis,  of  sugar,  of  phosphaturia,  etc. 

A  majority  of  cases  are  accompanied  by  general  debility  and  occur 
in  anaemic,  constipated  women  who  take  little  outdoor  exercise,  hence 
the  blood  also  should  be  examined  for  ansemia.  If  anaemia  be  present, 
an  ample  diet  should  be  prescribed,  accompanied  by  moderate  exer- 
cise and  abundant  fresh  air,  to  insure  more  perfect  oxidation.  Anstie 
says  correctly  that  "  neuralgic  patients  require,  and  greatly  benefit  by, 
a  nutrition  considerably  richer  than  that  which  is  needed  by  healthy 
persons."  This  is  particularly  true  of  the  extremes  of  age. 

Fats  and  oils  are  most  serviceable,  and  under  this  heading  cream, 
Devonshire  cream,  butter,  bacon,  fat  meat,  salad  oil,  olives,  and  cod- 
liver  oil  may  be  used. 

Neuralgic  patients  usually  dislike  fats,  perhaps  on  the  general  prin- 
ciple that  people  are  likely  to  prefer  different  food  from  that  which 
they  most  need  for  disordered  conditions  of  the  system.  Some  are 
made  bilious  by  fat,  but  with  a  little  tact  and  perseverance  in  se- 
lecting the  proper  kind  of  fatty  food  and  directing  the  mode  of  tak- 
ing it  these  objections  may  be  overcome.  Patients  may  take  more 
butter  than  usual,  though  they  refuse  cream,  or  they  will  take  diluted 
cream  though  they  refuse  cod-liver  oil.  Salad  oil  and  fat  bacon  are 
not  apt  to  provoke  objection. 

In  neuralgia  due  to  general  debility  or  anemia  without  lithiasis, 
proteids  are  indicated  in  addition  to  the  fats  above  mentioned,  and 
good  roast  beef,  beefsteak  or  chops,  eggs,  milk  with  bread  and  butter, 
light  starchy  foods,  and  fresh  vegetables  should  be  ordered.  Meat 
should  be  eaten  two  or  three  times  a  day,  and  additional  lunches 
may  be  given  between  meals,  consisting  of  milk,  a  glass  of  claret  and  a 
sandwich,  a  cup  of  cocoa  and  a  biscuit,  or  broth  thickened  with  beef 
meal  or  an  egg. 

Gowers  says  that  he  has  sometimes  known  "severe  neuralgia  to 
occur  first  on  the  patient  commencing  a  purely  vegetable  diet,  to 
disappear  when  meat  was  taken,  and  recur  with  severity  on  each  of 
four  successive  attempts  to  return  to  vegetarianism." 

If  the  nervous  system  has  been  greatly  overtaxed  or  the  digestive 


660         DIET   IN   DISEASES   OF   THE   NERVOUS   SYSTEM 

organs  are  exceptionally  feeble,  it  may  be  advisable  to  place  the  patient 
for  a  few  days  on  a  diet  consisting  largely  of  milk,  eggnog,  beef  broths, 
and  purees,  accompanied  by  rest  and  passive  exercise  (massage). 
After  a  few  days  the  more  substantial  proteid  foods  may  be  added. 
In  cases  associated  with  lithaemia  or  rheumatic  diathesis,  however,  the 
quantity  of  such  foods  should  be  reduced,  and  the  special  regulations 
described  under  the  heading  of  rheumatism  and  lithsemia  followed. 
(See  pp.  560,  713.) 

It  is  thus  seen  that  neuralgias  due  to  anaemia  and  debility  require 
diametrically  opposite  treatment  from  those  due  to  lithasmic  con- 
ditions. 

Coffee  and  tea  should  be  drunk  only  in  moderation,  and  in  serious 
cases  had  better  be  prohibited  altogether. 

Alcohol  in  restricted  dosage  benefits  many  anaemic  cases.  Claret 
or  Burgundy  may  be  drunk  with  meals,  but  alcohol  should  never  be 
taken  merely  to  relieve  pain  or  otherwise  than  a  food,  for  there  is 
danger  of  becoming  too  much  addicted  to  its  use. 

Substances  to  be  especially  forbidden  in  all  cases  are  pastry,  sweets, 
and  confectionery  of  all  kinds,  griddle  cakes,  condiments,  fried  food, 
and  rich,  highly  seasoned  sauces  and  foods. 

All  meals   should  be  eaten  at  regular   intervals,   and,   except  as 

directed  above,  eating  between  meals  is  prohibited. 

» 

Visceral  Neuralgias  in  General 

The  visceral  neuralgias  are  produced  in  the  sympathetic  nerves 
chiefly.  The  digestive  viscera  —  stomach,  intestines,  liver,  etc. —  in 
a  normal  state  are  free  from  sensory  impressions,  but  their  nerves 
are  constantly  conveying  reflex  impressions,  which,  however,  are  to  be 
distinguished  from  ordinary  tactile  sensibility.  Hypochondriasis,  by 
concentrating  mental  attention  upon  the  various  abdominal  viscera, 
undoubtedly  develops  hypersensitiveness  to  such  nerve  currents. 

The  condition  described  as  ptomaine  poisoning  and  various  forms  of 
autointoxication  may  excite  severe  visceral  neuralgias. 

Neuralgias  of  any  of  the  abdominal  viscera  may  be  excited  by  func- 
tional activity  (although  they  also  may  occur  independently  of  it), 
and  hence  the  diet  should  be  made  as  simple  as  possible,  in  order 
that  digestion  shall  not  be  unduly  prolonged.  If  any  one  article  of 
food  is  to  be  found  to  excite  the  paroxysms  it  should  be  abandoned. 
It  is  often  advisable  in  serious  cases  to  limit  the  diet  for  a  few 
weeks  to  two  or  three  articles  of  food,  such  as  beef,  bread,  milk, 
and  rice.  Details  of  treatment  are  described  under  the  following 
headings : 


GASTRALGIA  661 

Gastralgia 

Causation. —  In  neuralgia  of  the  stomach,  called  gastralgia,  or  gas- 
trodynia,  the  pain  is  situated  in  the  epigastrium,  penetrating  to  the 
back.  It  is  distinctly  localized  and  intense.  It  may  be  paroxysmal, 
or  there  may  be  dull,  constant  aching  with  exacerbations  of  a  mod- 
erate lancinating  character.  It  is  usually  relieved  somewhat  by  mod- 
erate gentle  pressure,  but  intensified  by  deep  pressure.  Such  pain  is 
not  infrequently  associated  with  anaemia,  chronic  constipation  and 
hysteria,  and  in  a  severe  form,  accompanied  by  violent  vomiting,  it- 
constitutes  the  '*  gastric  crisis  "  of  locomotor  ataxia.  Gastralgia  also 
may  be  occasioned  by  the  continued  excessive  use  of  stimulants,  such 
as  alcohol,  strong  tea  and  coffee,  and  chewing-tobacco,  and  by  the 
inordinate  use  of  sweets.  An  excessive  formation  of  hydrochloric  acid 
in  the  gastric  juice  may  occasion  a  very  painful  variety  of  gastralgia. 

Dietetic  Treatment. —  In  all  cases  of  gastralgia  careful  inquiry 
should  be  made  in  regard  to  irregularities  of  diet,  and  the  relation  be- 
tween eating  and  the  occurrence  of  the  pain.  If  the  pain  is  worse 
while  the  stomach  'is  empty  and  is  mitigated  by  taking  food,  it  is 
suggested  by  Gowers  that  it  is  due  to  morbid  action  of  those  nerves 
which  normally  excite  hunger.  Such  cases  should  be  treated  by 
giving  nourishment  in  frequent  small  quantities.  In  addition  to  the 
three  regular  meals  of  the  day,  which  should  be  light,  a  glass  of  wine 
or  a  cup  of  hot  bouillon  and  a  biscuit  or  two,  a  glass  of  milk  punch  or 
eggnog  or  a  custard,  may  be  taken  at  11  A.  M.,  4  p.  M.,  and  again 
before  retiring.  A  tumbler  of  milk  or  a  few  crackers  may  be  kept 
by  the  bedside  and  taken  in  the  middle  of  the  night  should  the  pa- 
tient be  awakened -by  the  pain.  The  pain  itself  is  an  indication  of 
impoverished  nutrition,  and  the  nervous  system  requires  rest  while 
the  tissues  need  food.  Hyperacidity  is  often  present  (p.  584).  In 
other  cases  food  intensifies  the  pain  and  excites  immediate  emesis. 
This  is  especially  true  of  the  gastric  crises  of  locomotor  ataxia,  for 
which  sedatives,  such  as  bismuth,  magnesia,  or  anodynes  may  be  given 
to  relieve  the  irritation  of  the  gastric  mucous  membrane  while  food 
is  temporarily  withheld  until  the  pain  has  subsided.  The  diet  sub- 
sequently should  be  increased  gradually,  commencing  with  small  quan- 
tities of  pancreatinized  albuminous  food,  and  followed  by  the  general 
Diet  for  Convalescence  given  on  page  472.  In  gastralgia  the  appetite 
is  very  capricious,  and  there  may  be  excessive  craving  for  certain  arti- 
cles of  diet,  such  as  pickles,  condiments,  etc. 

In  all  forms  of  gastralgia  the  pain  is  augmented  by  temporary  dis- 
tention  of  the  stomach.  If  starchy  food  tends  to  produce  flatulency 


662        DIET  IN  DISEASES  OF   THE  NERVOUS  SYSTEM 

it  should  be  avoided,  together  with  sugars  and  fats.  Tea,  coffee,  and 
tobacco  should  be  given  up.  The  bowels  should  be  kept  freely  open. 

Enteralgia  —  i.  e.,  a  true  neuralgic  pain  in  the  intestines  —  is  not 
common  if  "  peristaltic  unrest "  be  excluded.  It  does  occur,  however, 
and  oftenest  in  the  lower  rectum,  in  which  case  it  is  to  be  relieved  by 
local  medicinal  treatment  rather  than  dieting. 

Hepatalgia,  or  neuralgia  of  the  liver,  is  an  indication  of  functional 
overwork  of  that  organ,  which  may  be  relieved  by  a  careful  inquiry 
into  the  dietetic  habits  of  the  individual  and  correction  of  errors  in 
addition  to  purgation.  The  appropriate  diet  is  the  same  as  that  pre- 
scribed for  "  biliousness  "  on  page  647. 

In  severe  forms  of  neuralgia  which  do  not  yield  to  dietetic  and 
medicinal  control  prompt  relief  often  is  secured  by  change  of  scene 
and  sea  bathing,  or  a  course  of  mineral  baths.  Perspiration  may  be 
induced  by  electric  light  baths.  Hygienic  measures  improve  func- 
tional activity  and  promote  oxidation  and  assimilation  by  the  tissues 
of  the  products  of  digestion,  as  well  as  the  elimination  of  waste. 

MIGRAINE 

Migraine,  or  "  sick  headache,"  is  a  neurosis  characterized  by  pain 
in  the  course  of  the  fifth  nerve,  often  accompanied  by  nausea,  vomit- 
ing, mental  depression,  and  local  vasomotor  disorders. 

There  are  many  causes  assigned  to  this  affection,  among  them 
heredity,  the  gouty  diathesis,  improper  food,  etc.  Some  obstinate 
cases  are  unaffected  by  diet,  but  others  are  much  benefited  by  atten- 
tion to  it,  and  it  is  always  worth  while  to  attempt  a  cure  by  it.  The 
patient  should  be  closely  interrogated  in  regard  to  all  the  habits, 
of  diet  and  hygiene,  such  as  the  hours  for  eating,  the  kind  of  food 
eaten,  its  method  of  cooking,  bathing,  exercise,  mental  work,  hours  and 
frequency  of  the  stools,  etc.  In  this  way  only  may  possible  faults 
be  detected  and  corrected.  The  gouty  should  be  forbidden  the  use 
of  wines,  malt  liquors,  sugars,  and  starches.  The  ana?mic  should  be 
ordered  more  animal  food  and  fats  and  cod-liver  oil.  The  dyspeptic 
should  abstain  from  carbohydrates,  especially  sweets.  The  neurotic 
should  give  up  tea,  coffee,  and  tobacco.  It  has  been  shown  by  Eoberts 
that  both  tea  and,  to  a  lesser  extent,  coffee  may  materially  retard 
starch  digestion,  even  when  drunk  in  very  small  quantities.  Yet  there 
are  some  an.Tmic  patients  who  can  ward  off  an  impending  attack  of 
migraine  by  taking  two  or  three  cups  of  strong  tea  or  black  coffee. 

Plain  cereal  foods  may  be  allowed,  such  as  wheaten  grits,  "ger- 
mea,"  hominy,  and  oatmeal,  but  the  addition  of  milk  and  sugar  to 


MIGRAINE  663 

them  may  cause  fermentation  and  make  them  undesirable.     In  this 
case  saccharin  may  be  substituted,  or  an  extract  of  malt. 

Fresh  green  vegetables,  such  as  asparagus,  young  peas,  French 
beans,  string  beans,  sea-kale,  and  stewed  celery  may  be  eaten,  but  corn, 
cabbage,  cauliflower,  tomatoes  and  rhubarb  should  be  avoided. 

Excepting  very  anaemic  patients,  those  suffering  from  migraine 
should  not  eat  much  meat.  It  is  best  to  take  it  not  oftener  than  once 
every  other  day,  and  the  white  meat  of  poultry  and  broiled  fish  are 
better  than  any  red  meat.  Milk  may  disagree  and  cause  headache 
through  lactic-acid  fermentation,  interfering  with  digestion. 

New  bread,  pastry,  richly  cooked  foods,  fried  and  preserved  foods, 
condiments,  shellfish,  crustaceans,  cheese,  sauces,  and  desserts  in  gen<- 
eral  are  forbidden.  Many  of  these  foods  may  produce  ptomaines  by 
putrefactive  fermentation,  which  act  as  poisons  to  the  blood  and  nerves. 
Vinegar  and  acid  fruits  should  not  be  eaten,  especially  in  connection 
with  amylaceous  foods  (Roberts). 

Obviously  no  rules  of  diet  apply  to  all  cases  of  a  disease  which 
may  originate  from  so  many  different  sources,  and  in  chronic  cases 
careful  observation  and  experimentation  will  be  necessary  to  estab- 
lish the  best  course.  The  section"  on  Dietetic  Treatment  of  Intestinal 
Autointoxication,  p.  623,  may  be  applied  for  many  migraine  cases. 

Overeating,  irregular  eating,  and  late  suppers  should  be  forbidden. 
Outdoor  exercise  should  be  prescribed  to  aid  digestion,  and  the  bowels 
should  be  kept  active  by  eating  fruits. 

Patients  are  often  found  who,  as  a  result  of  following  every  one's 
advice,  have  gradually  cut  down  their  diet,  one  article  at  a  time,  until 
they  suffer  from  inanition,  and  it  requires  no  little  tact  and  firm- 
ness to  convince  them  that  they  can  eat  anything  at  all.  They  will 
live  on  nuts  and  fruits  alone,  or  on  hot  water  and  raw  beef,  or  follow 
the  latest  dietetic  "  fad,"  whereas  they  really  need  a  common-sense 
diet  of  plain,  nutritious  food,  such  as  that  prescribed  for  neuralgia  or 
anaemia  (pp.  539,  658). 

Decayed  teeth  are  a  frequent  cause  of  facial  or  other  neuralgias, 
and  the  pain  is  often  directly  excited  through  the  food  or  liquid  taken 
being  too  hot  or  too  cold,  or  strongly  sweet  or  sour.  Many  persons 
experience  temporary  but  severe  frontal  pain  after  swallowing  iced 
beverages  or  ice  cream  too  rapidly.  In  some  persons  the  site  of  the 
pain  is  in  the  vault  of  the  pharynx  or  in  the  throat.  It  is  relieved 
by  momentarily  compressing  both  carotid  arteries.  Lauder  Brunton 
suggested  that  cold  excites  the  sympathetic  plexuses  about  the  carotids 
and  alters  their  caliber,  putting  them  into  a  state  of  spasm.  These 
forms  of  neuralgic  pain  are,  however,  usually  trivial,  and  are  to  be 


664        DIET  IN  DISEASES  OF  THE  NERVOUS  SYSTEM 

avoided  by  proper  care  of  the  teeth  and  regulating  the  temperature  of 
the  food. 


NEURASTHENIA 

Causation. —  Neurasthenia  is  a  condition  of  loss  of  tone  of  the 
nervous  system  which  is  of  functional  rather  than  organic  character. 
•  It  is  also  called  nervous  exhaustion  or  nervous  prostration.  Strictly 
speaking,  it  is  not  a  disease,  but  rather  a  functional  derangement  of 
considerable  duration,  which,  however,  with  proper  care  and  dietetic 
treatment  results  usually  in  complete  recovery.  The  most  obvious 
cause  of  neurasthenia  is  overwork  of  the  nervous  system  due 
to  continued  excitement,  strain  or  prolonged  emotional  depression  and 
anxiety.  It  is  far  more  likely  to  be  produced  by  overwork  of  the 
nervous  than  of  the  muscular  system,  although  it  may  be  occasioned 
by  the  latter.  Different  persons  are  endowed  with  varying  degrees  of 
nerve  force,  and  the  complex  demands  and  great  activity  of  highly 
developed  civilization  tempt  or  compel  many  to  draw  upon  their  physi- 
ological capital  of  energy  at  the  expense  of  its  income,  with  the  re- 
sult of  exciting  the  entire  central  nervous  system,  including  both  brain 
and  spinal  cord,  to  an  unwonted  and  sometimes  dangerous  degree. 
For  this  reason  neurasthenia  is  essentially  an  affection  incident  to  the 
occupations  and  customs  of  city  life,  rare  or  comparatively  unknown 
in  the  repose  of  the  country.  It  is  a  curious  but  undeniable  fact  that 
there  appears  to  be  more  or  less  fashion  in  regard  to  some  diagnoses, 
in  nomenclature  at  least,  if  not  in  the  diseases  themselves,  and  of  late 
years  "  nervous  prostration "  has  taken  rank  among  ordinary  func- 
tional disorders. 

The  general  name  "  neurasthenia  "  includes  a  large  variety  of  nerv- 
ous symptoms,  and  while  all  of  the  physiological  processes  of  the  body 
are  more  or  less  impaired,  the  symptoms  may  predominate  in  one  or 
more  mechanisms,  as,  for  instance,  that  of  the  circulation,  gland  secre- 
tion, or  absorption. 

Men  who  find  themselves  in  business  straits  or  in  circumstances 
of  prolonged  anxiety  feel  that  they  are  straining  their  vital  powers, 
and  resort  to  an  increased  or  excessive  use  of  stimulants,  such  as 
alcohol,  tobacco,  coffee,  and  various  drugs,  to  excite  their  overtaxed 
mental  and  physical  powers  into  greater  activity.  By  means  of  this 
substitution  of  force,  especially  with  the  use  of  alcohol,  they  are  en- 
abled to  work  on,  and  still  further  excite  a  debilitated  nervous  system 
until  finally  the  limit  of  endurance  is  reached,  and  some  slight  addi- 
tional strain  reduces  them  to  utter  prostration. 


NEURASTHENIA  665 

Neurasthenia  reacts  especially  on  the  digestive  system,  producing 
malnutrition  and  a  variety  of  functional  disorders. 

General  Treatment. —  The  treatment  of  neurasthenia  is  fundamen- 
tally based  upon  three  essential  conditions :  First,  complete  body  rest, 
with  the  necessary  absence  of  the  original  exciting  cause  of  the  diffi- 
culty; second,  a  nourishing  diet,  to  supply  the  material  for  energy 
and  tissue  metamorphosis ;  third,  wholesome  mental  diversion  or  occu- 
pation. Various  tonics,  such  as  strychnine,  iron,  and  arsenic,  are  of 
recognized  benefit  to  the  nervous  system,  but  the  main  reliance  in 
treatment  should  be  placed  upon  rest,  food,  and  mental  or  moral  sup- 
port. The  milder  cases  may  be  relieved  in  addition  by  a  change  of 
occupation  and  the  enforcing  of  strict  rules  in  regard  to  the  hours  of 
sleep,  the  methods  and  time  of  eating  and  taking  exercise,  bathing, 
etc.  Many  persons  with  functional  nervous  disorder  have  no  appetite 
early  in  the  day,  but  towards  evening  can  eat  a  substantial  meal,  and 
they  should  dine  late. 

Patients  who  for  years  have  been  accustomed  to  exceedingly  active 
mental  work  find  it  almost  impossible  to  endure  confinement,  absence 
from  social  intercourse,  and  lack  of  occupation,  and  in  such  cases  the 
advantages  of  dietetic  treatment  may  be  enhanced  by  cheerful  sur- 
roundings and  diversion.  As  a  rule,  it  is  easier  for  the  fatigued  or 
worried  business  man  or  "  brain  worker  "  to  break  off  completely  his 
accustomed  occupation  for  a  period  of  several  weeks  or  months,  to  be 
spent  in  travel  or  at  some  foreign  or  domestic  spa,  than  it  is  for  him 
to  continue  his  ordinary  occupations  in  moderation,  and  take  exercise 
and  proper  food  and  sleep  at  home  in  accordance  with  the  rules  laid 
down  by  the  physician. 

In  many  cases  of  this  nature  travel  affords  a  certain  and  fairly 
prompt  relief,  but  it  has  the  disadvantage  that  it  involves  consider- 
able irregularity  in  the  hours  of  rest,  character  of  diet,  etc.,  as  well 
as  the  fact  that  many  are  deterred  from  this  means  of  cure  by  the 
expense  involved.  In  another  class  of  cases  too  active  traveling  is 
stimulating  and  fatiguing,  and  if  such  people  are  not  made  ill  at  sea 
nothing  gives  more  benefit  than  the  isolation,  invigorating  air,  and  en- 
forced idleness  of  a  sea  voyage.  For  others,  in  whom  the  digestive 
system  is  comparatively  little  impaired,  camping  or  living  an  outdoor 
life  in  the  woods  afford  the  same  advantage.  Whatever  journey  is 
undertaken,  therefore,  should  be  in  the  direction  of  rest  and  moderate 
diversion  without  the  "  sight-seeing  "  which  is  involved  in  visiting  new 
cities.  The  physician  not  only  should  study  carefully  the  previous 
habits  of  the  patient,  but  consult  his  tastes  in  regard  to  occupations  and 
amusements.  When  this  is  done  and  the  patient's  confidence  has  been 


€66        DIET  IN   DISEASES  OF   THE  NERVOUS  SYSTEM 

gained,  it  is  easier  to  have  the  rules  for  diet  which  are  prescribed  care- 
fully adhered  to.  In  still  another  class  of  cases  of  neurasthenia  the 
general  nerve  collapse  is  so  sudden  and  exhaustion  so  extreme  that 
absolute  rest  at  home  and  in  bed  is  imperative.  To  this  class  belong 
a  large  number  of  overworked  society  women  whose  lives  of  constant 
excitement  and  mental  activity  or  stimulation,  combined  with  the 
number  of  social  or  charitable  interests  or  other  occupations  to  which 
they  give  much  energy,  wear  them  out  in  time. 

This  type  of  patient  suffers  continual  depression  from  the  least  ex- 
ercise, exertion,  or  emotional  excitement.  It  is  not  easily  realized  by 
persons  in  health,  how  much  energy  is  expended,  i.  e.,  how  much  food 
fuel  is  consumed,  by  minor  muscular  activities,  yet  in  calorimeter 
experiments  it  may  be  shown  that  such  movements  as  turning  over 
in  bed,  raising  one  limb,  turning  the  pages  of  a  book,  etc.,  are  all 
measurable  degrees  of  effort  in  terms  of  foot  pounds  or  calories, 
which  in  the  feeble  neurasthenic  may  result  in  sensible  fatigue  re- 
actions, (p  12). 

In  some  instances  insomnia  is  a  predominant  and  serious  symp- 
tom ;  in  others  the  patient  is  drowsy  in  the  daytime  and  unable  to  per- 
form any  concentrated  mental  labor;  in  others  again  inanition  is  the 
most  pronounced  feature,  and  the  rapid  loss  of  weight  and  failure  of 
strength  alarms  the  patient,  or  the  body  may  increase  in  weight  from 
accumulation  of  fat  and  water  in  the  tissues,  while  the  muscles  be- 
come soft  and  so  feeble  as  scarcely  to  support  the  frame.  Many  cases 
are  complicated  with  pronounced  hysteria,  hypochondriasis,  unnatural 
irritability,  and  entire  lack  of  decision. 

One  of  the  first  requisites  in  treatment  is  to  secure  a  faithful  and 
intelligent  nurse  and  to  isolate  the  patient  from  well-meaning  but 
oversympathetic  friends  whose  constant  inquiries  and  suggestions 
magnify  existing  conditions  by  focusing  the  attention  of  the  patient 
upon  them.  In  general,  it  is  best  to  allow  no  one  to  see  the  patient  ex- 
cepting the  trained  nurse,  the  physician,  and  perhaps  some  one  trusted 
member  of  the  family.  All  business  matters  and  domestic  news  of  an 
exciting  or  depressing  character  should  be  kept  from  the  patient,  and 
such  connection  as  may  be  allowed  with  the  outside  world  should  only 
be  of  a  cheerful  and  encouraging  nature. 

It  is  very  important  that  the  nurse,  who  is  so  constantly  with  the 
patient,  should  be  congenial  and  possessed  of  the  requisite  tact  and 
cheerfulness  of  disposition.  Many  of  these  details  may  seem  trivial, 
but  their  importance  is  appreciated  after  experience,  which  shows 
how  easily  infringement  of  the  rules,  such  as  the  untimely  reception 
of  exciting  news  or  the  visit  of  an  untactful  friend,  may  react  upon 


NEURASTHENIA  667 

the  digestive  system  and  interrupt  the  favorable  progress  of  the  case 
for  several  days. 

To  be  of  any  service,  the  "  rest  cure  "  should  last  six  weeks  or  more, 
and  in  severe  cases  it  should  be  explained  to  the  patient  that  this  treat- 
ment by  no  means  completes  the  restoration  of  the  normal  nerve  func- 
tions, but  is  to  be  regarded  as  a  basis  for  a  further  regimen  of  exer- 
cise and  outdoor  life. 

The  "  Rest  Cure." — At  the  commencement  of  treatment  in  grave 
cases  the  patient  should  lie  absolutely  quiet  in  bed  and  not  be  even  al- 
lowed to  raise  the  arms  or  head  to  take  food.  After  a  week  or  ten 
days  of  such  enforced  and  absolute  rest,  the  patient  may  gradually 
be  allowed  to  sit  up  and  feed  herself,  but  usually  a  full  month  or  six 
weeks  should  be  spent  in  bed  with  no  further  exertion.  The  lack  of 
voluntary  exercise  should  be  supplied  by  the  tonic  effect  of  bathing 
and  massage.  The  patient  should  receive  a  sponge  bath  every  morn- 
ing soon  after  breakfast,  which  is  to  be  given  with  hot  water,  or  hot 
sea  water  if  it  can  be  obtained.  A  portion  of  the  body  only  is  to  be 
sponged  at  a  time,  and  friction  with  a  coarse  towel  should  immedi- 
ately follow.  In  some  cases  benefit  results  from  rubbing  a  piece  of 
ice  or  a  cloth  dipped  in  ice  water  over  the  skin  for  a  moment  after 
the  hot-water  sponging.  The  alternate  stimulation  of  the  cutaneous 
nerves  by  strong  degrees  of  heat  and  cold  always  produces  a  tonic 
effect,  and  the  influence  of  the  ice  water  and  friction  is  analogous  to 
that  produced  by  the  Brand  system  of  cold  bathing  in  typhoid  fever. 

After  the  bath,  which,  if  properly  given,  may  consume  a  half  or 
three-quarters  of  an  hour,  the  patient  is  left  alone,  and  at  noon  or  in 
the  early  afternoon  massage  is  to  be  given,  at  first  every  day,  later  on 
alternate  days.  At  the  commencement  of  the  case  the  massage  should 
be  exceedingly  mild,  and  caution  is  required  in  this  respect,  for  neu- 
rasthenic patients  are  often  injured  by  the  too  vigorous  or  prolonged 
efforts  of  the  massage  operators.  For  the  first  day  twenty  or  thirty 
minutes  will  suffice,  and  if  the  effect  is  favorable,  the  time  may  be 
gradually  extended  to  an  hour.  Owing  to  the  nature  of  the  diet, 
which  at  first  is  of  milk,  and  from  the  lack  of  exercise  and  loss  of  tone 
of  the  intestinal  walls,  neurasthenic  subjects  are  uniformly  con- 
stipated, and  the  massage  should  be  adapted  particularly  to  remedy 
this  difficulty  (p.  640). 

Dietetic  Treatment. —  The  feeding  of  the  patient  should  be  based 
upon  the  principle  of  giving  all  the  nourishment  which  can  be  as- 
similated. The  stools  should  be  watched  to  make  sure  that  the  food 
is  thoroughly  digested.  Xourishment  should  be  given  at  brief  inter- 
vals, depending  somewhat  upon  the  amount  of  time  allotted  to  sleep, 


668        DIET  IN  DISEASES  OF   THE  NERVOUS  SYSTEM 

but  in  cases  of  great  exhaustion  patients  should  not  be  permitted  to 
go  more  than  four  hours  at  any  time  without  food.  In  other  cases 
when  sleep  interrupted  for  feeding  is  regularly  resumed,  food  may  be 
given  with  regularity  once  in  three  hours  throughout  the  night,  and 
once  in  two  hours  during  the  day,  as  in  typhoid  fever.  When  improve- 
ment is  attained,  the  intervals  of  sleep  will  naturally  be  longer,  and 
it  will  be  both  unnecessary  and  unwise  to  awaken  the  patient  for  feed- 
ing. 

The  basis  of  the  diet  in  most  cases  should  be  milk,  and  by  study- 
ing the  taste  and  digestion  of  the  patient  it  is  usually  possible  to  pre- 
pare it  so  that  it  is  well  borne.  (See  Adaptation  of  Milk  for  the 
Sick,  p.  84.) 

In  commencing  the  milk  diet  the  objection  of  the  patient  often 
has  to  be  overcome,  and  it  is  advisable  to  begin  slowly,  giving  skim- 
med milk  in  tablespoonful  doses  four  or  five  times  a  day  for  two  or 
three  days  until  the  patient  is  accustomed  to  it.  Other  food  is  allowed 
at  first,  but  this  is  to  be  reduced  gradually  in  bulk  and  the  milk  sub- 
stituted for  it  in  increasing  quantity  until  four  ounces  of  skimmed 
milk  are  taken  every  two  hours.  It  ia  finally  given  up  to  eight  or  ten 
ounces  at  the  same  intervals.  The  taste,  if  disagreeable,  may  be  over- 
come by  the  addition  of  a  little  black  coffee  or  caramel.  If  it  pro- 
duces weight  and  episgastric  oppression  or  causes  flatulence  and 
eructations  it  is  to  be  diluted  by  one-half  or  one-third  with  lime,  bar- 
ley, or  rice  water  or  Vichy.  One  of  the  "prepared  foods,"  such  as 
Xestle's,  Mellin's,  or  Imperial  Granum  may  be  added,  or  the  milk 
pancreatinized  or  temporarily  replaced  by  koumiss,  zoolak  or  beef  juice 
and  albumen  water. 

The  constipation  which  the  milk  occasions  may  be  overcome  by 
a  pill  of  ox  gall  or  a  dose  of  bitter  water  in  the  morning,  or  by  enemata 
of  warm  soapsuds,  when  the  latter  do  not  produce  the  exhaustion 
which  occasionally  follows  their  use.  Many  patients  do  very  well  on 
the  exclusive  milk  diet  for  a  week  or  two,  and  they  may  be  fed  very 
much  as  typhoid-fever  patients  are,  excepting  that  they  may  take  more 
milk.  If  they  can  digest  it,  two  and  a  half  or  three  quarts  a  day 
should  be  given  as  recommended  by  Weir  Mitchell,  who  was  the 
pioneer  of  this  method  of  treatment  in  this  country.  After  five  or  six 
days  of  such  treatment  a  chop  or  a  poached  egg  may  be  added  at  noon. 
The  next  day  bread  and  butter  or  bread  and  milk  is  given,  besides,  for 
supper,  and  then  an  egg  or  a  little  meat  at  breakfast,  until  the  patient 
is  taking  three  good  meals  of  plain  food  daily,  but  in  addition  at  least 
two  quarts  of  milk.  The  exclusive  milk  diet  is  believed  to  prepare  the 
digestive  system  for  the  assimilation  of  other  foods. 


NEURASTHENIA  669 

Playfair's   Diet   for   Neurasthenia 

Playfair's  diet  for  neurasthenia  is  a  good  example  of  a  milk  diet, 
subsequently  combined  with  other  foods,  as  follows: 

First  Day. —  Twenty-two  ounces  of  milk  in  divided  doses. 

Second  Day. —  Fifty  ounces  of  milk  in  divided  doses. 

Third  Day. —  Fifty  ounces  of  milk  in  divided  doses.  Massage,  half 
an  hour. 

Fourth  Day. —  Fifty  ounces  of  milk  in  divided  doses;  egg,  bread 
and  butter;  dialyzed  iron,  forty  minims  in  two  doses  (continued 
daily).  Massage,  one  hour  and  a  half. 

Sixth  Day. —  Fifty  ounces  of  milk  in  divided  doses;  mutton  chop. 
Massage,  one  hour  and  fifty  minutes. 

Eighth  Day. —  Fifty  ounces  of  milk  in  divided  doses;  mutton  chop; 
porridge  and  a  gill  of  cream;  maltine,  twice  daily.  Massage,  three 
hours ;  electricity,  half  an  hour ;  continued  to  end  of  treatment.  The 
solid  food  is  now  gradually  increased  until  such  a  diet  is  reached  as  the 
following  for  the 

Tenth  Day. —  6  A.  M.,  raw  meat  soup,  ten  ounces ;  7  A.  M.,  a  cup  of 
black  coffee;  8  A.  M.,  a  plate  of  oatmeal  porridge,  a  gill  of  cream,  a 
boiled  egg,  three  slices  of  bread  and  butter,  and  cocoa;  11  A.  M., 
milk,  ten  ounces ;  2  P.  M.,  rump  steak,  one-half  pound  of  potatoes, 
cauliflower,  a  savory  omelet,  milk,  ten  ounces;  4  p.  M.,  milk,  ten 
ounces;  three  slices  of  bread  and  butter;  6  p.  M.,  a  cup  of  gravy 
soup;  8  P.  M.,  a  fried  sole,  roast  mutton  (three  large  slices),  French 
beans,  potatoes,  stewed  fruit,  and  cream;  milk,  ten  ounces;  11  p.  M., 
raw  meat  soup,  ten  ounces. 

Fifteenth  Day. —  Three  full  meals  daily  of  fish,  meat,  vegetables, 
cream,  and  fruit;  two  quarts  of  milk  and  two  glasses  of  Burgundy. 

Twenty-second  Day. —  Amount  of  food  lessened. 

Von  Leyden's  Diet  for  Neurasthenia 

Yon  Leyden's  diet  for  neurasthenia  is  a  modified  form  of  milk 
treatment  which  gives  excellent  results  in  some  cases : 

At  7  A.  M.,  half  a  liter  of  milk,  slowly  sipped  during  half  an  hour,  a 
small  cup  of  coffee  with  cream,  eighty  grams  (nearly  three  ounces) 
of  cold  meat,  a  mealy  baked  potato;  10  A.  M.,  a  liter  of  milk  with 
three  biscuits;  12  A.  M.,  the  same;  1  p.  M.,  broth,  two  hundred  grams 
(about  seven  ounces)  of  fowl,  puree  of  potatoes,  green  vegetables,  one 
hundred  and  twenty  grams  (nearly  four  ounces)  of  compote,  and 
pastry;  3.30,  5.30,  8,  and  9.30  P.  M.,  half  a  liter  of  milk,  making  a 
daily  consumption  of  three  liters  and  a  half  of  milk.  In  the  after 


670        DIET   IN   DISEASES   OF   THE   NERVOUS   SYSTEM 

part  of  the  day,  two  meals  each  of  eighty  grams   (three  ounces)  of 
roast  meat  with  bread  and  three  biscuits. 

Keating's  Diet  for  Neurasthenia 

Keating's  diet  for  neurasthenia  is  adapted  to  patients  who  need 
not  be  kept  constantly  in  bed.  It  is  as  follows: 

At  6  A.  M.,  a  tumblerful  of  strong  hot  beef  tea ;  8  A.  M.,  a  half  tum- 
blerful of  iron  water,  and  breakfast  of  fruit,  steak,  coffee,  and  a 
goblet  of  milk;  8.30  A.  M.,  a  goblet  of  milk  with  a  dessertspoonful  of 
malt  extract,  six  grains  of  citrate  of  iron  and  quinine;  10  A.  M.,  elec- 
tricity; 12  A.  M.,  a  goblet  of  milk  and  malt;  2  p.  M.,  dinner,  preceded 
by  a  half  tumblerful  of  iron  water  and  a  third  goblet  of  milk  and  malt ; 
6  P.  M.,  third  dose  of  iron  water.  Light  supper  of  fruits,  bread 
and  butter,  and  cream;  a  fourth  goblet  of  milk  and  malt;  10  p.  M., 
beef  soup,  four  ounces,  preceded  by  massage  with  cocoa  oil  for  an 
hour. 

Two  quarts  of  milk  are  taken  daily,  in  addition  to  all  other  food. 
The  patient  on  this  diet  is  allowed  to  be  out  of  bed  for  four  hours 
every  day,  one  of  which  may  be  spent  in  business. 

If  milk  cannot  be  made  to  agree  with  the  patient  in  any  form, 
meat  broths  and  purees  and  light  farinaceous  food  may  be  prescribed. 
Eggs  may  be  given  dropped  into  bouillon  or  any  of  the  preparations 
of  egg  albumen.  Meat  essences  and  extracts,  such  as  Liebig's  or 
Valentine's,  are  serviceable,  but  the  latter  are  so  merely  for  their 
stimulating  effect  upon  digestion.  If  the  condition  of  the  stomach 
is  good,  the  constipation  resulting  from  so  concentrated  a  diet  may 
be  overcome  by  the  use  of  oatmeal  porridge  for  breakfast,  whole- 
meal bread,  and  fresh  fruits,  such  as  the  juice  of  the  shaddock  or 
dried  or  stewed  prunes  or  figs. 

The  receipts  under  the  heading  "  Receipts  for  Invalid  Diet "  for  the 
several  kinds  of  fluid  food  will  enable  the  physician  to  prescribe  suffi- 
cient variety  to  stimulate  the  appetite  of  the  patient,  and  in  many 
cases  a  slightly  different  menu  can  be  ordered  for  each  day  in  the  week. 
Most  patients  after  a  fortnight  to  three  weeks  of  semisolid  diet  are 
able  to  digest  meat  and  other  solid  foods.  As  an  example  of  an  excel- 
lent typical  dietary  for  this  stage  of  the  treatment,  the  following  is 
given  by  H.  C.  Wood: 

At  S  A.  M.,  rolls  or  toast,  cocoa,  weak  coffee  or  roasted  wheat  cof-  . 
fee,  beefsteak,  tenderloin,  or  mutton  chop;  9  A.  M.,  bathing;  11  A.  M., 
oatmeal  porridge  with  milk  or  else  a  half  pint  of  molasses;  12  noon, 
massage:  2   r.   M.,  dinner,  bouillon  with  or  without  egg,  beefsteak, 
rice,  white  potatoes  roasted;  dessert  of  bread  pudding,  blancmange, 


NEURASTHENIA  671 

or  similar  farinaceous  articles;  4  p.  M.,  electricity;  5  p.  M.,  milk  toast; 
9  P.  M.,  a  half  pint  of  skimmed  milk  or  koumiss. 

Billinger  dissents  somewhat  from  other  teaching  and  believes  that 
a  modified  vegetable  diet  is  most  useful  in  the  treatment  of  neuras- 
thenia, being  less  irritant  to  the  nervous  system  than  a  preponderance 
of  animal  food,  and  for  anaemic  subjects  who  require  proteids  he  pre- 
scribes milk  and  oatmeal  porridge  and  preparations  of  ground  meal  of 
legumes.  He  allows  chocolate  and  cocoa  for  beverages.  A  vegetable 
diet  is  recommended  in  certain  chronic  cases  in  which  the  patient  is 
much  worried  over  the  smallness  and  infrequency  of  the  stools.  Ac- 
companied by  large  draughts  of  water  such  diet  begets  copious  and 
ready  evacuations.  For  this  purpose  such  vegetables  should  be  pre- 
scribed as  celery,  string  beans,  spinach,  peas,  and  potatoes  and  beans 
in  purees.  Graham  bread,  wheaten  grits,  and  cracked  or  shredded 
wheat  also  may  be  eaten.  Meat  should  not  be  allowed  more  than  once 
a  day. 

SUMMARY  OF  DESIRABLE  FOODS  FOR  NEURASTHENIA 

Light  luncheons  between  meals ;  a  cup  of  beef  juice,  two  beaten  eggs, 
baked  custard,  cup  of  malted  milk  or  Imperial  Granum,  chicken 
broth  with  crackers;  a  bottle  of  koumiss,  a  glass  of  cream  (one-third) 
and  Vichy  (two-thirds),  2  scraped-beef  sandwiches  and  a  glass  of 
claret  or  malt  extract,  a  saucer  of  stewed  fruit  with  rice ;  baked  apples 
and  cream;  cocoa  or  chocolate  with  sponge-cake,  or  macaroons. 

Breakfast:  A  grape  fruit  or  two  oranges,  bacon  and  eggs,  a  cereal, 
such  as  oatmeal,  hominy,  or  mush,  buttered  toast,  cup  of  cocoa  or 
postum,  or  hot  water  and  lemon. 

Dinner  (at  noon)  :  Beef  soup,  bread,  beefsteak,  mutton  chop, 
rare  roast  beef,  lamb  or  mutton,  boiled  mutton,  veal,  boiled  ham, 
white  or  baked  potatoes,  beans,  peas,  beets,  cauliflower,  tomatoes; 
lettuce  with  olive  oil,  butter  (added  to  bread,  potatoes,  steak,  etc.,  in 
abundance),  puddings  of  Indian  meal,  apple  or  bread,  with  sugar  and 
cream.  Stewed  fruit.  (There  is  no  objection  to  fish,  but  the  diet 
is  intended  to  make  the  patient  eat  a  maximum  of  meats,  with  bread, 
potatoes,  butter  and  cream,  and  not  "  fill  up  "  with  other  foods.) 

Supper:  Minced  chicken  or  lamb,  cream  toast,  a  fruit  omelette, 
chicken  or  calves'  foot  jelly,  apple  sauce  or  peaches,  or  berries  and 
cream,  cocoa  or  chocolate,  crackers  or  gingersnaps,  bread  and  butter. 

Electricity. —  The  use  of  the  electric  current  is  of  service  in  pro- 
moting the  nutrition  of  the  body  during  the  period  of  absolute  rest 
from  the  voluntary  movement.  It  should  be  remembered  that  the 
electric  current  possesses  no  special  nutritive  value  or  "  vitalizing " 


DIET  IN  DISEASES  OF   THE  NERVOUS  SYSTEM 

influence,  such  as  is  often  claimed  for  it,  but  that  it  acts  favorably 
upon  the  muscular  system  by  causing  the  muscles  to  contract,  and  in 
that  way  also  quickens  the  circulation.  The  contraction  of  muscles 
compresses  the  contents  of  their  lymphatic  vessels  and  venous  radicles, 
thereby  aiding  circulation,  while  the  phenomena  are  accompanied  by 
metabolism  which  involves  the  appropriation  of  the  ingredients  of 
the  food  which  have  been  absorbed.  The  f aradic  current  is  used  for 
this  purpose.  It  may  be  applied  to  special  groups  of  muscles  at  first, 
and  subsequently  to  the  entire  body.  Care  should  be  taken  not  to 
fatigue  individual  muscles,  and  the  current  should  be  carefully  regu- 
lated and  applied  in  accordance  with  the  condition  of  the  patient. 
The  use  of  electricity  in  relation  to  the  treatment  of  constipation  has 
been  referred  to  under  that  heading  (p.  641).  It  is  doubtful  whether 
the  local  application  of  electricity  over  the  abdominal  wall  exercises 
any  definite  influence  upon  the  digestive  processes  which  may  be  going 
on  in  the  viscera  beneath  the  electrodes.  The  use  of  electricity  serves 
to  occupy  and  interest  the  patient,  and  thus  make  easier  the  carrying 
out  of  the  more  essential  parts  of  treatment. 

INSOMNIA  AND  DISORDERED  SLEEP 

Insomnia  is  due  to  many  causes,  but  those  which  concern  die- 
tetics are  the  opposite  extremes  of  overfeeding  and  starvation  or  in- 
anition. Overfeeding  or  eating  improper  food  may  cause  disordered 
sleep,  nightmares,  or  temporary  insomnia  from  attacks  of  acute  in- 
digestion, dyspepsia,  or  biliousness,  but  inanition  or  malnutrition  is 
more  likely  to  cause  true  insomnia  from  exhaustion.  Intestinal  indi- 
gestion with  much  flatulence  may  develop  five  or  six  hours  after  a 
hearty  late  dinner  or  supper,  and  either  awaken  the  patient  or  cause 
restlessness,  jactitation  and  unrestful  sleep.  Neurasthenic  subjects 
whose  nerve  energy  is  insufficient  to  conduct  their  digestive  and  ab- 
sorptive functions  completely  are  very  liable  to  suffer  from  insomnia. 
They  unfortunately  resort  to  hypnotics,  instead  of  first  trying  the 
efficacy  of  dietetics. 

It  is  a  good  rule  in  such  cases  to  improve  the  nutrition  by  regulated 
feeding  at  frequent  intervals.  In  addition  to  three  good  meals  a 
day,  the  patient  should  be  made  to  take  a  quart  of  milk,  with  beef 
tea  and  one  or  two  ounces  of  malt  extract.  By  gradually  increasing 
the  diet  according  to  such  rules  as  those  given  for  the  treatment  of 
neurasthenia,  in  a  week  or  ten  days  the  patient  often  may  be  made 
to  reach  the  maximum  above  given,  and  improvement  is  almost 
certain  to  follow.  It  is  best  to  take  the  heaviest  meal  of  the  day  in 


VERTIGO  —  CHOEEA  673 

the  early  afternoon,  and  not  as  late  as  six  o'clock,  for  an  overloaded 
stomach  with  indigestion  is  itself  a  cause  of  insomnia,  but,  on  the 
other  hand,  going  to  bed  with  an  empty  stomach  is  usually  undesirable. 
In  mild  cases  a  glass  of  hot  milk,  a  couple  of  teaspoonfuls  of  meat 
extract  in  hot  water,  or  a  cup  of  good  beef  tea  and  a  biscuit,  or  a  cup 
of  cocoa,  or  chicken  broth,  or  a  light  sandwich  and  a  glass  or  two  of 
beer  or  ale,  taken  just  before  retiring,  will  serve  to  divert  the  blood 
current  from  the  brain  to  the  stomach  and  induce  cerebral  anasmia  and 
sleep  without  the  use  of  medicines,  strong  stimulants,  or  "  nightcaps," 
and  if  anodynes  have  to  be  given,  a  little  food  taken  in  this  manner 
increases  their  efficacy  and  makes  a  smaller  dose  possible. 

Elderly  persons  often  awaken  at  four  or  five  o'clock  in  the  morning 
and  are  unable  to  regain  sleep.  If  they  take  a  little  food  at  this  time, 
a  few  crackers  and  a  glass  of  milk,  or  cup  of  hot  bouillon,  they  often 
will  at  once  go  to  sleep.  It  is  inconvenient  to  rise  and  heat  food  at 
this  hour,  but  a  non-radiating  double  bottle  has  been  devised,  having 
vacuum  between  its  two  layers,  which  will  keep  hot  fluids  hot,  or  cold 
fluids  cold  for  many  consecutive  hours. 

VERTIGO 

Vertigo,  although  it  arises  from  many  causes,  very  often  may  be 
occasioned  by  digestive  disorders,  such  as  the  production  of  flatulency 
with  palpitation,  or  by  the  absorption  of  products  of  indigestion 
which  act  as  irritants  of  the  vascular  system.  Such  products,  for  ex- 
ample, are  developed  in  some  persons  by  eating  shellfish,  strawberries, 
etc.  (See  Autointoxication,  p.  623).  Lack  of  sufficient  food  may 
cause  it. 

The  dietetic  treatment  is  that  of  dyspepsia  (p.  579).  Fats  and 
sugars  are  forbidden,  and  alkaline  and  laxative  waters,  such  as  Con- 
gress, or  Hathorn  water,  are  of  service  to  open  the  bowels  and  increase 
the  activity  of  the  kidneys.  Lithaemic  patients  should  be  kept  for  a 
week  or  two  upon  a  vegetable  diet  (p.  560).  In  most  cases  of  vertigo 
the  diet  recommended  for  biliousness  (p.  647)  should  be  followed. 

CHOREA 

Mild  cases  of  chorea  require  no  special  regulation  of  diet  beyond 
that  which  is  directed  towards  the  prevention  of  flatulent  dyspep- 
sia (p.  584)  and  constipation  (p.  636).  In  more  pronounced  cases  it 
is  sometimes  advisable  to  order  the  patient  for  a  time  upon  a  milk 
diet.  Sweets  and  farinaceous  foods  should,  as  a  rule,  be  forbidden 
45 


674        DIET  IN  DISEASES  OF   THE  NERVOUS  SYSTEM 

for  fear  of  increasing  palpitation  through  exciting  flatulence.  Other 
patients  do  better  with  a  diet  of  animal  food  without  meat,  consisting 
of  fish,  eggs,  and  oysters  with  bread  and  milk,  koumiss,  or  zoolak. 
They  are  prone  to  anaemia,  and  should  be  encouraged  to  take  as 
much  food  as  the  digestive  organs  will  tolerate.  Cod-liver  oil  and 
cream  are  useful. 


EPILEPSY 

Epilepsy  is  a  functional  nervous  disorder,  which  may  often  be 
improved  by  attention  to  diet.  A  very  large  proportion  of  cases  ap- 
pear in  childhood  at  a  period  when  existing  functional  derangements 
of  the  nervous  system  are  readily  intensified  by  improper  food. 
Rhachitic  children  with  imperfect  development  of  the  teeth,  feeble 
digestive  organs,  and  consequent  malnutrition  may  acquire  epilepsy 
while  teething.  Many  cases  are  closely  associated  with  errors  in  diet 
or  affections  of  the  alimentary  canal,  and  while  such  conditions  do  not 
cause  the  disease,  they  readily  precipitate  epileptic  seizures.  This 
statement  applies  to  grand  mal  and  petit  mal  rather  than  to  the 
localized  or  partial  convulsions  know  as  Jacksonian  epilepsy.  Of  the 
varieties  of  epilepsy,  petit  mal  is  more  favorably  influenced  by  diet 
than  are  the  other  forms. 

Patients  should  have  their  eating  supervised  with  care.  They 
should  be  well  fed,  but  eat  only  easily  digestible  food  and  have  their 
meals  at  regular  intervals,  and  the  principal  one  in  the  middle  of  the 
day,  in  order  that  digestion  at  night  may  be  completed  before  going  to 
sleep.  All  food  should  be  eaten  slowly,  and  meat,  if  given,  should  be 
masticated  very  thoroughly,  and  the  stomach  should  never  be  over- 
loaded. Meat  should  be  allowed  only  two  or  three  times  a  week. 
Some  children  with  petit  mal,  or  even  grand  mal,  improve  rapidly  on 
a  strictly  vegetarian  diet  or  on  a  bland  diet  of  which  milk,  bread  and 
butter,  and  simple  farinaceous  foods,  such  as  rice  pudding,  cornstarch, 
Indian-meal  pudding,  etc.,  form  the  basis.  I  have  seen  cases  of  epi- 
lepsy among  young  children  in  which,  while  the  medicinal  treatment 
remained  constant,  a  return  to  meat  diet  was  invariably  followed  by 
convulsions,  which  were  absent  on  a  vegetable  or  exclusive  milk 
regimen. 

As  a  rule,  adults  do  not  seem  to  be  aided  by  dieting  to  such  a 
degree  as  children:  nevertheless,  they  do  well  to  eat  very  little 
meat  and  to  be  abstemious  and  regular  in  their  habits  of  eating.  Dr. 
Mersan.  of  the  West  Riding  Asylum,  in  England,  tried  the  experi- 
ment of  putting  a  number  of  chronic  epileptics  for  some  weeks  first 


EPILEPSY  675 

upon  a  diet  of  flesh  and  then  upon  a  vegetable  diet,  and  vice  versa. 
The  results  showed  that  their  convulsions  were  not  materially  lessened 
in  number  or  severity,  but  it  was  noticed  that  while  their  food  con- 
sisted largely  of  meat  their  mental  condition  was  more  stupid.  At  the 
epileptic  colony  of  Chalfont  St.  Peter,  the  patients  are  allowed  meat 
once  a  day,  but  all  the  inmates  are  men,  leading  an  active  outdoor  life, 
and  hence  better  able  to  digest  stimulating  proteid  food.  Gowers, 
on  the  contrary,  allows  his  patients  meat  twice  a  day,  and  asserts  that 
he  has  seen  cases  in  which  fewer  epileptic  seizures  occurred  while 
eating  flesh  than  when  abstaining  from  it.  One  patient  had  par- 
oxysms only  after  eating  beef,  but  not  in  connection  with  other  va- 
rieties of  meat.  It  is  evident  that  no  definite  rule  should  govern  all 
cases.  It  is  worth  while  to  reduce  the  proteid  food  for  a  month  or 
two,  and  if  improvement  does  not  follow,  or  nutrition  becomes  less 
active,  it  may  again  be  added  to  the  dietary. 

Dr.  Whitmore  Steele,  formerly  of  the  Utica  State  Asylum,  in 
speaking  of  the  treatment  of  chronic  epilepsy  at  that  institution,  in- 
forms me :  "  We  endeavor  to  reduce  the  amount  of  albuminous  foods, 
giving  a  more  liberal  and  easily  assimilated  diet  also.  Invariably 
overalimentation  in  our  epileptics  produces  attacks."  Chronic  epi- 
leptics and  epileptic  degenerates  will  often  gorge  themselves  with  food 
and  drink  if  allowed  to  do  so. 

Some  of  the  carnivores,  as  well  as  animals  accustomed  to  a  mixed 
diet,  like  the  felines,  develop  convulsions  from  a  too  liberal  allowance 
of  meat,  if  at  the  same  time  they  are  kept  in  confinement.  In  these 
cases,  however,  the  convulsions  may  be  due  to  reflex  irritation  from  the 
stomach  or  bowels,  produced  by  large  masses  of  slowly  digested  food, 
rather  than  to  the  chemical  nature  of  the  food.  The  same  thing  may 
occur  in  young  children  who  are  allowed  to  gorge  themselves  with 
any  hastily  eaten  bulky  diet,  and  the  resulting  convulsions  should  not 
be  confounded  with  genuine  epileptic  seizures  accompanied  by  loss  of 
consciousness,  and  recurring  periodically.  Some  patients  have  a  dis- 
tinct epigastric  aura  preceding  the  convulsions.  Joseph  Collins,  of 
ISTew  York,  gave  a  salt-free  diet  (described  on  p.  556)  to  25  epileptics, 
with  a  reduction  of  one-third  in  the  number  of  their  attacks. 

It  is  extremely  desirable  to  prevent  intestinal  putrefaction,  the  diet 
for  which  condition  is  given  on  page  623.  Should  the  stools  become 
very  offensive,  or  Tnuch  flatulence  or  indicanuria  appear,  the  patient 
first  should  be  given  a  milk  diet  for  a  week  or  two,  and  cathartics  and 
intestinal  antifermentatives  should  be  employed,  such  as  salol,  creosote, 
or  guaiacol  carbonate,  and  lactobacilline  (p.  92). 

Many  are  obliged  to  take  large  doses  of  the  bromides  and  other 


676        DIET  IN  DISEASES  OF  THE  NERVOUS  SYSTEM 

medicines.  It  will  be  found  that  the  disagreeable  symptoms  of 
bromism  are  less  likely  to  occur  if  the  diet  be  so  regulated  as  to  avoid 
constipation  and  to  insure  the  consumption  of  abundant  fluid  diluents. 
Vichy  or  carbonic-acid  water  and  water  should  be  drunk  freely  be- 
tween meals,  and  especially  after  taking  medicine,  and  daily  thorough 
evacuations  of  the  bowels  should  be  secured  by  the  use  of  fresh  vege- 
tables and  fruits,  such  as  prunes,  figs,  apples,  oranges  (the  latter  to  be 
taken  with  water  between  meals),  etc.  Adults  should  abstain  from 
agents  which  are  likely  to  over-stimulate  the  nervous  system,  such  as 
alcohol,  strong  tea  and  coffee.  The  use  of  tobacco  also  should  be  in- 
terdicted. 

BERI-BERI 

Beri-beri,  or  kakke,  is  a  form  of  multiple  neuritis  very  rarely  im- 
ported into  this  country  by  Chinese,  Ceylonese,  Japanese,  or  Philip- 
pine Islanders,  who  have  acquired  it  in  their  native  countries  or  on 
the  voyage.  It  is  characterized  by  anaemia,  general  oedema,  and  more 
or  less  stiffness  and  paralysis  of  the  extremities,  with  dyspnoea  and 
serous  effusions.  Sometimes  there  are  muscular  spasms. 

Beri-beri  has  been  attributed  to  the  absence  of  fresh  animal  food 
from  the  diet,  a  sort  of  antithesis  to  the  cause  often  assigned  to 
scurvy.  It  has  more  specifically  been  attributed  to  the  excessive 
consumption  of  rice  and  adzuki  beans  to  the  exclusion  of  other  food. 
According  to  Oshima,  prior  to  1883,  thirty-two  per  cent  of  the 
Japanese  marines  suffered  from  this  disease,  their  diet  being  extremely 
low  in  proteid.  In  1884  a  new  food  supply  act  went  into  effect  for 
the  navy,  which  greatly  increased  the  protein  ration,  and  within  three 
years  the  disease  was  practically  exterminated  from  the  navy.  Similar 
results  were  obtained  in  the  Japanese  army  through  the  effort  of  the 
former  Surgeon-General,  Baron  Takaki. 

LOCOMOTOR  ATAXIA 

Locomotor  ataxia  is  a  disease  which  cannot  be  said  to  be  particu- 
larly influenced  by  any  system  of  dietetic  treatment,  although  it  is 
believed  by  some  writers  that  the  quantity  of  meat  ordinarily  eaten 
should  be  reduced.  As  in  many  other  forms  of  very  chronic  nervous 
disease,  a  generous  diet  is  desirable,  with  an  abundance  of  fat,  butter, 
cream,  cod-liver  oil,  etc..  when  the  stomach  will  tolerate  it.  Strong 
liquors  should  be  forbidden,  but  light  wines,  malt  liquors,  tea,  and 
coffee  may  be  allowed  in  moderation.  A  reasonable  use  of  tobacco 
need  not  be  proscribed. 


APOPLEXY  677 

In  those  cases  in  which  the  "  gastric  crises  "  predominate  the  diet 
should  be  restricted  for  a  few  days  when  the  crises  occur,  upon  the 
principles  established  for  the  treatment  of  gastralgia.  (See  p.  661.) 
It  may  be  necessary  at  such  times  to  order  a  simple  bread  and  milk 
diet. 

Other  diseases  of  the  spinal  cord  usually  do  not  demand  particular 
dietetic  treatment,  but  Bauer  says  that  "  some  diseases  of  the  spinal 
cord  lead  to  an  extraordinary  falling  off  of  the  demand  for  nutri- 
ment." This  is  due  to  alterations  in  general  metabolism,  and  is  most 
striking  in  cerebrospinal  meningitis. 

APOPLEXY 

The  several  forms  of  cerebral  hemorrhage  may  interfere  with  nu- 
trition in  a  variety  of  ways.  If  coma  be  present,  voluntary  degluti- 
tion being  suspended,  great  care  is  to  be  exercised  in  feeding  the 
patient.  Liquid  food  is  best  given  in  teaspoonful  doses,  and  the 
effect  of  each  spoonful  should  be  watched  to  see  that  it  is  successfully 
swallowed  before  another  is  given,  otherwise  fatal  choking  may  result 
from  food  passing  over  an  insensitive  epiglottis  and  larynx,  when  par- 
ticles may  be  drawn  into  the  lungs  and  excite  aspiration  pneumonia. 
Concentrated  meat  extracts,  beef  peptonoids,  and  peptonized  milk  may 
be  given  in  this  manner. 

When  rigidity  of  the  jaw  interferes  with  feeding,  or  when  paralysis 
involves  the  mechanism  of  deglutition,  a  long,  slender  catheter  may 
be  introduced  through  the  nose  and  passed  into  the  stomach,  through 
which  fluid  nourishment  is  poured,  after  the  manner  of  feeding  pa- 
tients suffering  from  melancholia.  (See  Melancholia,  p.  680.) 

The  rectum  may  be  utilized  for  nutrient  enemata  (p.  455).  In 
unilateral  facial  paralysis  without  unconsciousness  patients  may 
be  willing  and  able  to  swallow,  but  mastication  is  difficult  or  impos- 
sible. The  food  constantly  passes  into  the  buccal  cavity  behind  the 
teeth  of  the  paralyzed  side,  and  the  tongue,  perhaps  also  partially 
paralyzed,  dislodges  it  with  great  difficulty.  The  retention  of  food 
is  accompanied  by  a  copious  secretion  of  saliva,  which,  dribbling 
from  the  depressed  angle  of  the  mouth,  adds  greatly  to  the  discom- 
fort of  the  patient.  All  nourishment  should  therefore  be  given  in 
fluid  form,  or  in  such  finely  divided  state  that  it  does  not  require 
mastication,  and  may  readily  be  washed  down  with  water.  Milk, 
thick  broths,  purees  thickened  with  macerated  vegetables,  long-boiled 
rice,  sago,  or  barley  with  cream,  custards,  soft-cooked  eggs,  etc., 
may  be  given.  The  patient  should  be  fed  very  slowly  to  prevent  the 


678         DIET  IN   DISEASES  OF   THE   NERVOUS   SYSTEM 

food  from  running  out  of  the  mouth.  The  mouth  should  frequently 
be  cleansed  with  hydrogen  peroxid  and  a  saturated  aqueous  solu- 
tion of  boric  acid.  In  cases  of  hemiplegia  without  facial  paralysis  the 
patient  can  masticate  and  swallow,  but  the  mental  condition  or  loss 
of  appetite  makes  the  use  of  such  food  desirable  as  may  be  swallowed 
with  the  least  possible  effort.  Convalescent  hemiplegic  patients 
having  a  very  protracted  recovery  suffer  from  lack  of  exercise,  and 
almost  invariably  become  constipated.  It  is  well  in  such  instances 
to  recommend  simple  and  non-nitrogenous  diet,  containing  laxative 
food,  such  as  cooked  fruit,  and  coarse  cereals,  to  regulate  the  bowels. 
It  is  important  to  reduce  arterial  tension,  to  prevent,  if  possible,  a 
repetition  of  the  intracranial  hemorrhage.  Large  draughts  of  fluid 
rapidly  absorbed  tend  by  adding  to  the  volume  of  the  blood,  to  increase 
temporarily  the  intravascular  pressure  (p.  528).  The  bloodvessels, 
however,  show  a  very  remarkable  ability  to  maintain  an  average 
pressure  of  the  fluid  within  them,  and  the  possible  danger  from  this 
source  of  an  exclusive  fluid  diet  may  be  averted  by  increasing  the 
functional  activity  of  the  kidneys  by  diuretics  and  reducing  the  ar- 
terial tension  by  the  remedies  in  common  use,  such  as  chloral,  nitro- 
glycerin,  and  the  nitrites.  When  the  tension  is  very  high,  it  is  well 
to  give  a  bland  diet  without  much  meat,  and  bread  and  milk  and 
cereals  with  cream  should  form  the  basis  of  it.  Alcoholic  stimulants 
should  be  forbidden. 

ACUTE   INSANITY  — MELANCHOLIA  — PRIMARY   DE- 
MENTIA —  MANIA 

Acute  insanity  may  result  from  overwork  or  severe  mental  strain, 
or  from  numerous  diseases.  It  overtaxes  the  vital  powers  and  causes 
wasting,  inanition,  and  exhaustion.  As  the  symptoms  may  result 
quite  suddenly,  often  within  a  few  hours  after  intense  emotional 
strain  or  excitement,  the  digestive  system  is  at  first  not  disturbed  to 
any  considerable  extent,  although  the  appetite  may  be  absent  entirely. 
Subsequently  various  digestive  disorders  and  malnutrition  supervene. 

The  insane,  especially  the  melancholic,  often  refuse  food  abso- 
lutely, or  can  be  induced  to  take  it  only  very  sparingly. 

Forced  Feeding. —  When  food  is  refused  by  the  patient,  the  ques- 
tion of  forced  feeding  should  be  considered  in  order  to  tide  him  over 
the  emergency  and  support  life  until  confusional  insanity  or  delirium 
subsides. 

Concerning  this  problem  opposite  views  are  held.  Some  alien- 
ists regard  the  operation  of  compulsory  feeding  as  good  mental  dis- 


MELANCHOLIA  —  MANIA  679 

cipline,  others  decry  it,  and  defer  it  as  long  as  possible.  It  should  be 
understood  that  the  refusal  of  food  may  be  either  a  complication  or 
a  symptom  of  the  special  form  of  insanity  in  which  it  occurs,  and  the 
patient  should  be  studied  to  determine  which  condition  is  present. 
As  a  complication,  it  may  be  caused  by  central  nerve  lesions  that 
hinder  deglutition,  such,  for  example,  as  those  found  in  either  acute 
or  chronic  paralytic  dementia.  Or  digestive  disturbances,  dyspepsia, 
or  gastric  catarrh  may  cause  a  loss  of  appetite  which  in  the  patient's 
disturbed  mental  state  is  exaggerated  into  a  refusal  of  all  food.  Such 
local  disorders  may  themselves  cause  hallucinations  or  delusions, 
giving  rise  to  "  sitophobia,"  or  horror  of  taking  food.  Obviously  in 
such  cases  cure  of  the  complication  may  be  effected  by  treating  the 
local  condition.  Lavage  will  sometimes  relieve  it  entirely. 

When  the  refusal  of  food  is  purely  a  symptom  of  the  disease,  as 
it  occurs  in  melancholia  or  delusional  insanity,  an  attempt  always 
should  be  made  to  learn  the  exact  nature  of  the  delusion,  and  to  try 
whether  it  cannot  be  dispelled  or  offset,  as  in  the  case  of  some  para- 
noiacs.  For  example,  the  delusion  may  apply  merely  to  food  cooked 
in  particular  ways,  or  served  in  a  certain  manner  or  by  certain  per- 
sons, and  the  patient  may  have  no  real  loss  of  appetite,  but  may 
try  to  obtain  food  by  stealth  and  be  pleased  at  his  success  in  that  di- 
rection, and  his  food  should  be  placed  where  he  can  find  it  unobserved. 

Some  patients  will  refuse  liquid  foods  who  are  willing  to  take  solids, 
or  vice  versa,  or  they  may  refuse  food  offered  by  an  attendant  and  yet 
accept  it  from  a  fellow-patient. 

If  their  delusions  take  the  form  of  suspicion  of  poisoning,  they 
sometimes  may  be  overcome  by  showing  them  eggs  in  the  shell,  milk 
in  sealed  bottles,  unpeeled  potatoes  and  fruits,  which  obviously  cannot 
have  been  poisoned  beforehand,  and  which  are  then  cooked  in  their 
presence.  Some  patients  will  only  eat  if  left  alone  or  after  others 
have  finished,  because  they  feel  unworthy  to  eat  with  them.  I  have 
sometimes  persuaded  others  who  persistently  refused  food  to  take  it 
greedily  if  an  apparent  show  of  force  was  made  in  placing  it  within 
their  mouths. 

Patients  with  chronic  or  asthenic  mania  may  refuse  food  from 
inattention,  although  able  to  eat  if  their  surroundings  are  quiet  and 
their  attention  can  be  momentarily  obtained.  If  they  can  be  induced 
to  take  but  a  few  mouthfuls  at  a  time  they  should  be  fed  repeatedly 
at  short  intervals. 

Food  should  be  cooked  and  served  as  temptingly  as  possible,  and 
the  patient,  if  unable  to  keep  himself  in  order,  should  have  his 
mouth  cleansed  and  clothing  protected  from  soiling. 


680        DIET  IN  DISEASES  OF   THE  NERVOUS  SYSTEM 

The  appetite  is  seldom  a  safe  guide  in  insanity,  and  when  it  fails 
completely  forced  feeding  should  not  be  postponed  until  the  patient 
has  become  too  exhausted  to  rally.  Cases  of  depressive  insanity  are 
apt  to  require  it  sooner  or  later,  and  sometimes  it  is  practiced  con- 
tinuously for  a  year  or  more.  In  acute  mania,  however,  it  may  only  be 
necessary  to  employ  the  method  for  a  few  days,  after  which  the 
patient  will  eat  of  his  own  accord  if  given  the  opportunity. 

In  a  former  service  in  the  Bloomingdale  Asylum,  with  cases  of 
melancholia,  after  one  or  two  feedings  with  the  stomach  tube,  I  have 
sometimes,  by  a  little  firmness  and  patience,  satisfied  the  patient 
that  swallowing  a  glass  of  milk  himself  was  more  agreeable  than 
having  it  poured  in  through  a  tube.  When  voluntary  starvation 
is  the  fixed  intent,  owing,  perhaps,  to  a  delusion  of  command  from 
some  higher  power,  if  the  patient  can  be  convinced  that  he  has  to  take 
food  in  some  manner,  he  may  yield  to  the  inevitable  and  choose  the 
lesser  of  what  he  regards  as  two  evils.  With  a  stomach  tube  in  one 
hand  and  a  glass  of  milk  in  the  other  the  argument  for  choice  may 
be  made  very  forcible. 

The  physician  himself  should  always  direct  the  passage  of  the 
tube  for  the  first  few  times.  Afterwards,  if  the  patient  be  not  refrac- 
tory, an  attendant  may  do  it.  Occasionally  the  aid  of  two  or  three 
assistants  is  necessary  to  overcome  resistance.  The  patient  should 
be  made  to  sit  down  or  lie  upon  his  back,  and  either  an  cesophageal 
or  nasal  tube  may  be  used,  according  to  the  directions  given  on  p. 
599.  There  are  certain  advantages  in  the  use  of  each  tube.  The 
cesophageal  tube  does  not  so  readily  admit  of  regurgitation  alongside 
of  it  as  the  nasal  tube  does  (although  occasionally  patients  can  re- 
gurgitate through  the  tube  itself).  If  it  be  filled  before  it  is  inserted, 
and  if  a  little  fluid  be  squeezed  out  of  it  when  part  way  down  the 
oesophagus,  reflex  swallowing  occurs,  which  may  be  taken  advantage 
of  to  further  propel  the  tube.  The  disadvantage  of  this  method  of 
feeding  is  that  the  patient  often  struggles  and  must  be  gagged.  A 
wooden  gag  shaped  like  a  bit,  with  a  central  perforation  through 
which  the  tube  is  passed,  prevents  it  from  being  compressed  by  bit- 
ing. But  the  gag  is  disagreeable,  it  may  slip  and  break  a  tooth,  and 
the  head  and  arms  must  be  rigidly  held  by  two  assistants.  I  have 
known  a  refractory  patient  with  melancholia  to  bite  off  and  swallow 
eleven  inches  of  stiff  oesophageal  tube,  which  remained  in  the  stom- 
ach for  eleven  days  before  it  was  ejected  by  vomiting ! 

The  nasal  tube  possesses  the  advantage  that  it  may  more  easily  be 
introduced  with  much  less  struggling,  but  it  has  the  disadvantage 
that  greater  care  is  required  to  prevent  passing  it  into  the  larynx, 


MELAXCHOLIA  —  MANIA  681 

for  the  insane  are  sometimes  strangely  insensitive.  The  former  diffi- 
culty may  be  obviated  by  making  the  patient  speak,  or  closing  the 
tube  after  it  has  been  inserted  and  before  fluid  is  introduced,  in 
order  to  make  sure  that  breathing  is  not  obstructed.  This  form  of 
tube  should  be  of  as  large  a  size  as  can  be  passed  conveniently.  A  N"o. 
8  catheter  will  serve.  To  prevent  the  patient  from  pulling  out  the 
tube,  his  arms  may  be  wrapped  in  a  large  sheet  wound  several  times 
around  the  body,  after  the  manner  employed  with  gavage  for  a 
struggling  infant. 

For  forced  alimentation  it  is  necessary  to  give  food  in  fluid  form, 
and  a  quart  of  milk,  with  one  or  two  beaten  eggs,  either  raw  or 
slightly  cooked  or  made  into  eggnog,  may  be  prescribed  two  or  three 
times  a  day.  Nutritious  meat  broths,  thickened  with  barley,  rice,  or 
vermicelli  and  strained,  or  potato  puree,  may  also  be  given  through 
a  large  tube.  Cream  and  cod-liver  oil  should  be  added  to  the  diet. 
In  a  case  reported  by  H.  Cf.  Wood,  for  six  weeks  the  patient  lived 
with  the  greatest  benefit  on  six  pints  of  milk  and  sixteen  raw  eggs 
taken  daily.  If  an  ounce  of  malt  extract  be  added  to  oatmeal, 
hominy,  or  potato  gruel  in  milk,  it  soon  makes  the  mass  sufficiently 
fluid  to  pass  through  the  tube.  As  this  method  of  feeding  prevents 
the  saliva  from  commingling  with  the  food,  there  is  additional  ad- 
vantage in  giving  malt  or  diastase  to  replace  it. 

For  obstinate  patients,  feeding  with  the  tube  twice  a  day  —  at  say 
8  A.  M.  and  5  or  6  P.  M. —  is  sufficient,  and  a  quart  of  food  may  be 
introduced  at  once,  but  more  feeble  patients  require  feeding  three  or 
four  times  in  2-i  hours. 

If  gastric  catarrh,  gastric  dilatation  or  dyspepsia  is  present,  pre- 
liminary lavage  may  be  employed,  and  then  food  and  medicines  may 
be  poured  through  the  tube. 

Both  hypnotism  and  primary  anaethesia  under  chloroform  have 
been  utilized  in  extreme  cases  to  enable  food  to  be  given  to  the  in- 
sane, but  the  latter  method  is  only  necessary  or  justifiable  in  very 
exceptional  cases. 

Nutrient  enemata  are  of  little  value  in  the  feeding  of  the  insane 
who  resist  feeding,  for  if  the  patient  realizes  their  use  he  can  make  it 
more  difficult  to  be  nourished  in  this  way  than  by  the  stomach  or 
nasal  tube,  although  I  have  seen  patients  who  would  submit  to  it 
who  refused  mouth  feeding. 

Suralimentation  is  to  be  recommended  when  feasible.  It  is  de- 
scribed on  page  514. 

Brush    says :     "  In    acute    delirious    mania,    in    melancholia    with 

frenzy,  and  in  some  of  the  maniacal  seizures  incident  to  the  aged,  the 
46 


682  DIET  IN   SKIN  DISEASES 

great  importance  of  a  liberal  persistent  use  of  milk,  eggs,  and  animal 
broths  cannot  be  overestimated." 

If  patients  will  eat  they  should  be  given  abundant  nutritious  food, 
such  as  tender  meats,  custards,  cereals  with  butter,  sirup,  or  cream, 
eggnog,  thickened  broths,  purees,  beef  jelly,  gruels,  etc.,  which  are 
made  palatable  to  tempt  the  appetite,  and  the  number  of  daily  meals 
may  be  increased  or  nourishment  may  be  given  once  in  three  hours. 
By  diverting  the  blood  current  and  nervous  energy  for  digestive  proc- 
esses, the  general  nervous,  system  and  mental  condition  become 
soothed  and  quieted,  and  the  mind  improves  as  nutrition  gains. 
Mens  sana  in  corpore  sano.  Fresh  fruit  and  fruit  juices  should  be 
offered  occasionally. 

Special  Precautions. —  In  acute  insanity  there  is  a  tendency  for  the 
body  temperature  to  fall  two  or  three  or  more  degrees  below  the 
normal.  This  is  especially  true  of  those  cases  of  primary  dementia 
which  are  due  to  exposure  and  privation  accompanied  by  severe 
mental  strain,  such,  for  example,  as  occur  from  shipwreck  or  from 
any  form  of  severe  sudden  shock.  While  regulating  the  diet,  there- 
fore, attention  should  be  given  to  the  preservation  of  the  body  heat, 
and  the  patient  should  be  surrounded  by  uniform  temperature,  to 
be  maintained  in  an  overheated  room  or  by  hot-water  bottles  and 
warm  clothing.  Sustaining  the  normal  temperature  will  facilitate 
the  digestive  functions. 

The  insane  need  to  be  closely  supervised  while  eating.  They 
often  bolt  their  food,  when  given  too  much  at  a  time,  in  a  manner  that 
soon  destroys  digestion.  In  such  cases  all  food  should  be  served  in 
a  state  of  fine  subdivision  or  fluid  or  semifluid  form.  Patients  with 
advanced  general  paresis  or  different  paralytic  diseases  may  suffocate 
by  impacting  a  piece  of  meat  in  the  larynx.  Patients  with  mania 
gravis,  or  suicidal  melancholia,  etc.,  should  of  course  never  be  in- 
trusted with  knives  or  with  plates  or  dishes  which  may  be  broken 
into  sharp  fragments  with  which  to  cut  themselves  or  others. 

DIET  IX  SKIX  DISEASES 

It  long  has  been  known  that  a  relation  exists  between  various 
errors  in  diet  and  certain  skin  diseases,  but  it  is  only  within  the  past 
few  years  that  attention  has  been  directed  to  the  importance  of  sys- 
tematic dietetic  treatment  to  aid  the  cure  of  such  ailments,  and  a 
more  thorough  investigation  of  this  subject  is  much  to  be  desired. 

Skin  Diseases  Which  are  Caused  by  Improper  Diet. —  The  skin  dis- 
eases commonly  referable  among  other  influences  to  dietetic  errors  are 


DIET  IN   SKIN  DISEASES  683 

erythema,  urticaria,  acne,  eczema,  psoriasis,  exfoliative  dermatitis,  and 
scorbutic  eruptions. 

Many  chronic  skin  diseases,  if  not  originally  caused  by  dietetic 
errors,  are  undoubtedly  much  protracted  and  made  worse  by  them. 
This  is  particularly  true  of  impetiginous  and  seborrhceic  ecthyma, 
strophulus,  and  cutaneous  lesions  of  the  tuberculous  diathesis. 

Alcohol  beverages  drunk  in  excess  intensify  many  forms  of  chronic 
cutaneous  lesions,  notably  those  of  syphilis  and  rosacea,  and  the  capil- 
lary congestion  and  muddy  complexion  of  chronic  alcoholism  is  well 
known. 

The  modes  of  production  of  cutaneous  eruptions  by  dietetic  errors 
are  various.  Probably  in  the  majority  of  instances  such  eruptions 
are  due  to  irritation  by  malfermentation  products,  ptomaines,  etc., 
which  are  absorbed  through  the  digestive  tract.  (See  Autointoxica- 
tion, p.  623.)  In  other  cases  they  may  be  due  to  an  effort  to  eliminate 
incompletely  oxidized  food  products  or  poisons  from  the  cutaneous 
glands  (as  in  the  case  of  drug  rashes),  and  it  has  been  suggested  that 
they  sometimes  may  be  caused  by  reflex  nerve  irritation  from  the  ali- 
mentary canal,  although  the  latter  theory  is  less  tenable.  It  is,  how- 
ever, interesting  to  observe  the  fact  that  an  intimate  relation  often 
exists  between  irritation  and  inflammation  of  the  skin  and  of  mucous 
membranes.  Overeating,  and  especially  the  overfeeding  of  infants, 
is  a  common  cause  of  skin  eruptions,  and  the  attempted  elimination 
by  the  sweat  glands  of  fatty  acids  is  irritant. 

General  Principles  of  Dietetic  Treatment. —  There  are  certain  gen- 
eral principles  of  dietetic  treatment  which  are  applicable  to  a  major- 
ity of  all  severe  cases.  The  food  should  be  of  elementary  kind,  re- 
stricted in  variety,  and  plainly  cooked.  Milk,  eggs,  and  stale  bread  are 
more  desirable  than  amylaceous  or  saccharine  food.  If  fever  be  pres- 
ent at  the  outset,  a  milk  diet  should  be  ordered.  The  tuberculous 
and  gouty  require  fats  in  some  form.  Chronic  cases  with  malnutri- 
tion and  ana?mia  require  abundant  nourishing  animal  food.  In  scor- 
butic eruptions  the  trouble  arises  sometimes  (but  not  always)  from 
malnutrition  from  withholding  particular  foods,  such  as  fresh  fruit 
and  vegetables,  from  the  diet.  (See  p.  763.) 

Substances  to  be  avoided  in  skin  diseases  are  raw  and  unripe  fruits 
and  vegetables,  sweets  and  pastry  of  all  kinds,  condiments  and  highly 
seasoned  dishes,  fried  foods,  butter,  oils,  lard,  and  other  fats  (except 
in  tuberculous  cases),  veal,  pork,  and  alcoholic  beverages.  Other 
injurious  foods  will  be  mentioned  under  the  treatment  of  the  several 
varieties  of  skin  diseases  described  below.  The  underlying  dietetic 
principle  is  to  restore  the  balance  of  nutrition,  not  to  enforce  an 


684  DIET  IN   SKIN  DISEASES 

inflexible  routine, —  for  example,  eczema  in  one  patient  may  do  better 
with  vegetarianism,  but  in  another  with  a  meat  diet,  according  to 
general  conditions  of  nutrition. 

ERYTHEMA  —  URTICARIA 

Either  acute  erythema  or  urticaria  may  be  caused  in  some  persons 
by  eating  fish,  and  particularly  shellfish  and  crustaceans,  as  oysters, 
clams,  lobsters,  shrimps,  and  crabs.  It  also  occasionally  is  produced 
by  strawberries,  bananas,  and  other  forms  of  fruit.  Crustaceans  and 
strawberries  are  perhaps  the  most  common  excitants,  but  there  are 
many  curious  examples  of  individual  peculiarities. 

The  action  of  the  food  poison  is  different  from  that  of  ptomaines 
(p.  419),  for  it  originates  from  fresh  as  well  as  stale  food,  and  may 
be  derived,  as  in  the  case  of  strawberries,  from  vegetable  food.  Some 
persons  have  an  attack  regularly  every  spring  when  strawberries  first 
appear  on  the  table.  Others  show  occasional  immunity,  depending 
upon  their  condition  at  the  time. 

Those  persons  who  are  hurt  by  one  kind  of  poisonous  food  are  not 
necessarily  affected  by  the  others.  The  whole  matter  seems  to  be 
influenced  solely  by  idiosyncrasy. 

Other  alimentary  substances  which  have  been  observed  sometimes 
to  poison  are  pork  in  various  forms,  sausages,  mushrooms,  eggs, 
cheese,  and  mutton. 

Symptoms. —  The  eruption  develops  suddenly  and  within  from  two 
to  six  hours  after  ingestion  of  the  food.  It  is  commonly  a  typical 
urticaria  with  large  pink  wheals,  which  quickly  come  and  go  over  all 
parts  of  the  body.  They  are  accompanied  by  intense  itching  and 
burning.  This  affection  usually  lasts  only  a  few  hours,  or  possibly 
for  several  weeks. 

Treatment. —  The  eruption  usually  disappears  upon  withdrawing 
the  offending  article  from  the  diet,  giving  a  saline  cathartic  and  some 
simple  remedy  to  regulate  digestion  and  prevent  fermentation,  such 
as  salol,  salicin,  or  rhubarb  and  soda.  Lactobacilline  should  be  tried 
(p.  92).  Large  quantities  of  water  should  be  drunk,  8-10  glasses 
a  clay  between  meals. 

The  troublesome  itching  is  relieved  best  by  sponging  with  com- 
mon baking  soda,  a  teaspoonful  to  a  quart  of  water,  or  a  solution  may 
be  applied  to  the  wheals  of  menthol  and  chloral,  each  a  drachm,  in  a 
couple  of  ounces  of  a  mixture  of  equal  parts  of  alcohol  and  camphor 
water.  A  1-40  carbolic-acid  solution  may  be  similarly  applied  over 
kthe  affected  parts  of  the  body. 


ACNE  —  ECZEMA  685 

ACNE 

Causation. —  The  larger  number  of  cases  of  acne  are  produced  by 
improper  food.  The  papules  and  pustules  which  constitute  acne  are 
formed  by  inspissation  of  the  oil  of  the  sebaceous  glands,  which  plugs 
their  orifices  and  irritates  the  glands  and  the  hair  follicles,  exciting 
inflammation  in  them  with  pyogenic  bacteria.  The  disease  is  usually 
first  observed  during  puberty,  a  period  in  which  important  changes 
in  the  nutrition  of  the  body  are  in  progress,  and,  once  established,  it  is 
liable  to  last  for  some  time  —  often  for  several  years.  It  is  easy  to 
conceive  how  slightly  altered  composition  of  the  blood,  due  to  im- 
perfect assimilation  of  food,  may  modify  the  composition  of  the  sebum 
and  irritate  the  sebaceous  glands. 

In  some  patients  the  papules  appear  as  a  result  of  eating  buck- 
wheat cakes  or  oatmeal.  In  others  they  are  caused  by  greasy  food  — 
doughnuts,  sausages,  cheese,  fried  meats,  ill-cooked  and  rich  pastry  — 
excess  of  sweets,  nuts,  and  other  indigestible  substances. 

Dietetic  Treatment. —  In  addition  to  local  means,  and  the  recent 
treatment  according  to  Sir  A.  E.  Wright's  method,  with  homologous 
vaccines,  the  dietetic  treatment  of  acne  is  most  important.  G.  T.  Jack- 
son says :  "  The  well-to-do  are  all  prone  to  eat  too  much,  and  it  is  re- 
markable how  rapidly  acne  will  improve  by  reducing  their  diet  to  the 
simplest  elements.  In  many  of  them  a  milk  diet  for  a  few  days,  pro- 
vided milk  agrees  with  them,  will  accomplish  marked  benefit.  It  is  a 
good  rule  to  cut  off  from  the  dietary  all  pastry,  cake,  candy,  sweets,  hot 
breads  and  pancakes,  greasy  soups,  articles  fried  in  fat,  twice-cooked 
meats,  rich  gravies  —  in  fact,  all  those  things  that  are  most  apt  to 
tempt  the  palate."  Alcohol  in  all  forms  should  be  prohibited,  as  well 
as  tea  and  coffee.  A  tumblerful  of  hot  water  or  a  glass  of  Vichy  should 
be  drunk  before  each  meal.  With  meals  little  fluid  should  be  taken, 
never  over  four  or  five  ounces,  but  between  meals  water  or  aerated 
water  should  be  drunk  freely  for  its  diuretic  effect.  Exercise,  bathing, 
and  the  use  of  laxatives  should  be  adjuncts  to  the  dietetic  treatment. 

ECZEMA 

Causation. —  Eczema,  both  acute  and  chronic,  which  constitutes  so 
large  a  proportion  of  all  cases  of  skin  diseases,  is  provoked  by  different 
causes,  but  in  a  great  number  of  instances  its  origin  is  directly  trace- 
able to  dietetic  faults.  These  may  be  of  three  kinds  —  namely,  the 
eating  of  (1)  too  much  food;  (2)  insufficient  food;  (3)  improper 
food. 


686  DIET  IN  SKIN   DISEASES 

1.  Cases  Due  to  Overeating. —  The  ills  of  overeating  have  been  de- 
scribed on  page  411.  Its  relation  to  eczema  consists  in  the  additional 
burden  imposed  upon  the  skin  of  attempting  to  eliminate  waste 
products,  which  are  accumulated  in  the  blood  faster  than  they  can  be 
got  rid  of.  The  cutaneous  glands,  like  the  kidneys,  are  constantly 
stimulated  and  overworked,  and  the  character  of  their  secretion  is 
altered.  The  skin,  for  a  long  time  irritated,  finally  succumbs  to  a 
definite  eruption. 

It  is  for  this  reason  that  robust  persons  apparently  in  the  best 
of  health  and  with  too  vigorous  appetites  sometimes  will  be  surprised 
with  the  sudden  appearance  of  eczema,  which  they  have  always  at- 
tributed solely  to  "  bad  blood,"  i.  e.,  to  some  disease  taint. 

Treatment. —  This  class  of  cases  is  to  be  treated  by  reducing  the 
quantity  of  food,  and  prescribing  a  very  simple  diet.  In  cases  of  in- 
tractable general  eczema  it  may  be  best  to  order  the  patient  a  milk  or 
bread-and-milk  diet  for  one,  two,  or  three  weeks.  From  two  to  two 
and  a  half  quarts  are  taken  daily  with  toast  or  crackers.  Marked  im- 
provement will  occasionally  follow  this  course.  For  others,  reducing 
the  diet  by  excluding  meat  and  desserts  for  a  time,  may  be  all  that 
is  necessary.  Eed  meats  —  either  beef,  beefsteak,  mutton,  lamb,  or 
veal  —  should  not  be  allowed  more  than  once  a  week.  H.  G.  Piffard 
reports  that  56  per  cent  of  his  patients  were  accustomed  to  eat  meat 
in  excess  three  times  a  day. 

Fish,  either  boiled  or  broiled,  may  be  substituted  for  meat  to 
advantage  in  neurotic  subjects  (L.  D.  Bulkley),  for  though  it  may  ex- 
cite urticaria,  it  does  no  harm  in  eczema  in  spite  of  the  popular  belief 
to  the  contrary.  I  have  known  the  eating  of  shellfish,  however,  to  in- 
tensify chronic  cases  considerably. 

Typical  Diet. —  The  following  simple  diet  may  serve  as  an  example : 

Breakfast. —  Fresh  fruit,  bread  and  milk,  porridge,  wheaten  grits, 
cracked  wheat,  without  cream,  but  salt  or  lemon  juice  may  be  added 
if  preferred.  Every  other  day  a  soft-cooked  egg  may  be  eaten.  Cocoa 
or  postum. 

Dinner. —  ISTo  soup,  entrees,  or  dessert.  Chicken  may  alternate  with 
broiled  fresh  fish,  one  or  two  green,  light  vegetables,  such  as  haricots, 
spinach,  lettuce,  green  peas,  or  macaroni,  with  tomatoes.  As  Jackson 
says :  "  It  is  a  good  rule  to  tell  the  patient  he  may  eat  what  he  likes, 
but  not  of  more  than  two  dishes  at  a  meal.  It  is  unlikely  that  he 
will  then  overeat."  Fresh,  ripe  fruits,  except  apples,  may  be  allowed. 

Supper. —  Bread  or  toast  or  crackers  and  milk,  custard,  omelette, 
scrambled  eggs,  or  sweetbread  and  junket,  wine  jelly,  or  simple  rice 
pudding,  not  too  sweet.  Fresh  fruit  is  desirable.  Stimulants  are 


ECZEMA  687 

not  usually  required,  and  malt  liquors  of  all  sorts,  as  well  as  wines, 
expressly  should  be  forbidden.  It  is  generally  believed  that  tea  and 
coffee  are  harmful  in  eczema,  and  drunk  in  excess  they  certainly  are 
so,  not  only  from  disordering  and  retarding  digestion,  but  from  their 
undue  stimulating  effect.  Unless  they  be  taken  in  great  moderation 
and  only  once  a  day,  it  is  better  to  forbid  their  use  entirely.  The 
same  is  true  of  sweet  chocolate,  but  cocoa  may  be  allowed. 

2.  Cases  Due  to  Insufficient  Food. —  Too  little  food  results  in  im- 
poverished nutrition,  and  the  skin,  being  one  of  the  most  sensitive 
organs  of  the  body,  is  among  the  first  to  suffer.     The  habits  of  filth 
which  so  often  accompany  semi-starvation  among  the  poor  are  con- 
tributing causes  which  combine  to  provoke  skin  eruptions. 

The  diet  required  for  these  cases  differs  essentially  from  those  of  the 
preceding  class  by  addition  of  meats,  butter,  and  cream.  An  effort 
should  be  made  to  restore  the  impoverished  nutrition  of  the  body  as 
quickly  as  possible  by  suralimentation  if  necessary  (p.  514). 

3.  Cases  Due  to  Improper  Food. —  Improper  food  is  capable  of 
exciting  outbreaks  of  eczema,  and  this  is  particularly  true  of  chronic 
or  relapsing  cases.     Oatmeal,  for  example,  while  it  may  not  cause 
the  disease,  is  generally  believed  to  be  capable  of  intensifying  it.     It 
is  not  possible  always  to  forewarn  against  the  particular  articles  of 
diet  which  will  do  this,  as  they  vary  in  different  persons  and  often  in 
the  same  person  at  different  times,  but,  in  general,  food  which  is  called 
"  rich  "  is  to  be  avoided,  such  as  highly  seasoned  meats,  soups,  sauces, 
gravies,  strong  condiments,  sweets,  pastry,  pies,  puddings,  cake,  cakes 
and  sirup,  canned  dried  foods,  hot  breads,  much  butter,  lard,  pickles, 
preserves,  and  fancy  desserts  of  all  kinds.     Bulkley  especially  for- 
bids sweet  potatoes,  fried  eggplant,  cabbage,  cheese,  bananas,  apples, 
soda  water  with  sirups,  as  well  as  salt  food,  such  as  ham,  corned  beef, 
and  salt  pork.     A  little  bacon  or  a  salt  herring,  however,  is  permissible. 
All  fried  food,  with  the  above  exceptions,  is  strictly  forbidden,  and 
"  fritters,"  fried  oysters,  etc.,  are  highly  injurious.     In  a  word,  all 
those  articles  which  are  liable  to  excite  temporary  dyspepsia  and  over- 
load the  urine  with  phosphates,  urates,  and  calcium  oxalate  should 
be  avoided.     The  staple  diet  should  consist  of  whole-meal  bread,  fresh, 
plainly  cooked  vegetables,  eggs,  milk,  and  a  little  chicken,  or  fresh 
fish,  with  red  meat  not  oftener  than  once  or  twice  a  week. 

There  are  obstinate  cases  of  chronic  eczema  which  fail  to  yield  to 
any  dietetic  regulations,  but  it  is  desirable  always  to  try  the  value 
of  dietetics,  and  often  the  result  will  be  surprisingly  gratifying.  In 
conjunction  with  dietetic  treatment  the  urine  should  be  examined,  and 
the  bowels  kept  active. 


688  DIET  IN  SKIN  DISEASES 

It  is  very  important  to  control  the  general  habits  of  the  patient 
in  regard  to  meals.  He  should  eat  at  regular  and  proper  hours  and 
observe  uniformity  in  the  quantity  of  food  consumed.  He  should 
be  careful  to  eat  slowly  and  thoroughly  masticate  his  food,  and  not 
drink  so  much  fluid  with  meals  as  to  dilute  the  gastric  juice  excessively. 
The  general  rules  for  the  treatment  of  dyspepsia  (p.  583)  and  its 
avoidance  are  especially  applicable  to  all  skin  diseases  which  are  in 
any  way  amenable  to  dietetic  influence.  Eczema  frequently  is  associ- 
ated with  gouty  and  tuberculous  diatheses,  and  the  reader  is  referred 
to  the  sections  upon  these  subjects  (pp.  505,  717). 

Eczema  in  Nursing  Infants 

L.  D.  Bulkley  points  out  that  eczema  in  nursing  infants  mainly  is 
due  to  dietetic  errors  of  the  mother,  for  whom,  rather  than  for  the 
child,  treatment  should  be  instituted.  He  prohibits  the  drinking  of 
all  forms  of  malt  liquors,  wines  and  rich  chocolate.  Anything  which 
provokes  indigestion  and  biliousness  in  the  mother  reacts  unfavor- 
ably upon  the  skin  disease  of  the  infant.  This  is  an  important  truth 
too  often  overlooked.  If  the  mother  becomes  constipated,  has  dys- 
pepsia and  a  furred  tongue,  and  excessive  deposit  of  urates  and  oxa- 
ates  in  the  urine,  her  diet  should  be  changed  (according  to  the  rules 
for  dyspepsia  on  p.  583),  the  bowels  regulated,  and  tonics  given. 
Other  cases  in  infants  are  caused  by  the  mother's  milk  being  poor  and 
tkin,  and  the  breast  milk  should  be  supplanted  by  cow's  milk  properly 
prepared,  or  it  may  become  necessary  to  wean  the  baby  completely. 
Mothers  occasionally  nurse  their  infants  too  long,  hoping  thereby  to 
postpone  conception.  When  the  breast  milk  is  too  poor  in  quality 
Bulkier  believes  in  adding  fat  to  the  baby's  nourishment  in  the  form 
of  a  few  drops  of  cod-liver  oil  or  a  little  cream,  and  he  recommends 
inunctions  of  almond,  sweet  linseed,  or  cod-liver  oil.  Cod-liver  oil  is 
cited  by  some  authorities  as  causing  eczema,  but  this  refers  to  its  use 
in  excess  when  the  digestion  is  deranged  and  dyspepsia  is  aggra- 
vated b}'  it.  Eczema  sometimes  is  often  cured  by  adding  fat  to  the 
food. 

The  common  mistake  of  nursing  infants  too  often  is  particularly 
observed  with  eczematous  babies,  whose  mothers  mistake  the  child's 
crying  for  a  manifestation  of  hunger,  whereas  it  is  excited  by  the 
extreme  itching  of  the  eruption,  which  the  infant  is  too  young  or  too 
feeble  to  scratch.  If  fed  oftener  than  once  in  two  hours  or  longer, 
the  infant's  digestion  becomes  deranged,  and  any  existing  eruption 
i>  made  move  unbearable.  Bottle-fed  infants  are  more  likely  to  have 
eczema  than  sucklings,  probably  because  they  oftener  have  gastro- 


EXFOLIATIVE   DERMATITIS  —  ROSACEA  689 

intestinal  disorders.     Underfed  infants  are  less  subject  to  the  disease 
than  are  the  overfed. 

Eczema  in  Children 

Eczema  in  young  children  often  is  due  to  dietetic  errors,  and  in 
all  cases  care  should  be  exercised  to  cure  it  by  regulation  of  the  food. 
The  commonest  fault  in  feeding  very  young  children  consists  in  giv- 
ing them  too  much  farinaceous  food,  and  the  innumerable  prepared 
infant  foods,  consisting  largely  of  starches  and  sugars,  are  responsi- 
ble for  much  of  this  trouble.  Some  parents,  aware  of  this  fact,  go  to 
the  other  extreme,  and  give  the  child  too  much  animal  food  in  the 
form  of  meat  juice,  broths,  and  eggs.  A  diet  improperly  balanced 
in  either  direction  induces  a  "  bilious  "  condition  with  a  special  tend- 
ency to  the  development  of  eczema.  Older  children  should  be  denied 
candy,  chocolate,  pastry,  jams,  preserves,  and  indulgence  in  sweets  of 
all  sorts,  and  be  fed  upon  the  simplest  diet,  in  which  starch,  and 
especially  sugar,  is  reduced,  and  pure  fat  increased.  The  latter  is  to  be 
prescribed  in  the  form  of  cream,  fresh  uncooked  butter,  fat  beef,  and 
cod-liver  oil.  Bulkley  recommends  the  use  of  whole-meal  bread, 
cracked  wheat,  hominy,  and  corn  grits  with  salt  and  butter  or  cream. 
Oatmeal  is  prohibited;  likewise  tea  and  coffee. 

EXFOLIATIVE  DERMATITIS 

In  exfoliative  dermatitis  I  have  seen  more  benefit  from  an  exclu- 
sive milk  diet  for  a  month  or  six  weeks  than  from  any  other  treat- 
ment, combined  with  intestinal  irrigation  and  asepsis.  G.  T.  Jack- 
son advises  chewing  flaxseed  or  taking,  in  milk,  several  ounces  of 
flaxseed  tea  every  day.  Subsequently  it  should  be  treated  upon  sub- 
stantially the  same  dietetic  plan  as  eczema. 

ROSACEA 

Causation. —  Eosacea  is  a  chronic  skin  affection  disfiguring  the  mid- 
dle parts  of  the  face,  about  the  nose,  mouth,  cheeks,  and  sometimes 
the  forehead,  by  red  patches  of  dilated  capillaries. 

It  is  regarded  as  a  reflex  neurosis  of  the  local  vasomotor  nerves. 
It  is  oftenest  caused  by  erroneous  diet,  and  especially  by  strong  drink, 
which  dilates  the  facial  arterioles  and  also  excites  gastric  catarrh. 
Jackson  says :  "  The  inordinate  use  of  strong  tea  acts  in  the  same 
way,  and  probably  gives  rise  to  as  many  cases  as  does  alcohol." 

Dietetic  Treatment. —  The  dietetic  treatment  is  very  important.     It 


690  DIET  IN   SKIN  DISEASES 

involves  the  prohibition  of  all  alcoholic  drink,  as  well  as  hot  beverages 
of  every  kind,  such  as  tea  and  coffee,  and  also  soup.  Existing  dys- 
pepsia should  be  treated,  and  all  rich  food,  desserts,  sauces,  pickles, 
strong  condiments,  fat,  dried,  salted,  or  canned  foods,  fried  sub- 
stances, and  sweets  and  desserts  should  be  withheld.  The  patient 
should  be  kept  for  several  weeks  or  months  upon  a  low,  non-stimulat- 
ing diet  of  plainly  cooked  food,  such  as  that  advised  for  the  treatment 
of  eczema  (p.  686). 

PSORIASIS 

Causation. —  Psoriasis  is  a  chronic  general  skin  disease  characterized 
by  the  appearance  of  isolated  red  patches  of  considerable  size,  covered 
by  shining  white  scales.  The  etiology  of  this  eruption  is  not  under- 
stood. It  may  be  hereditary  or  follow  nerve  shock,  but  in  many 
cases  it  is  directly  attributable  to  imperfect  assimilation  of  nourish- 
ment, and  accumulation  of  waste  products  in  the  system,  such  as 
takes  place  in  gout  and  chronic  rheumatism.  The  excessive  consump- 
tion of  oatmeal  has  been  observed  to  develop  an  attack  (Hardaway). 
It  has  great  tendency  to  recurrence. 

Dietetic  Treatment. —  The  disease  is  less  amenable  to  dietetic  treat- 
ment than  are  some  other  skin  affections ;  nevertheless,  this  should  not 
be  neglected,  as  it  may  prove  a  valuable  aid  to  local  measures.  The 
diet  always  should  be  restricted  both  in  quantity  and  variety.  Obese 
and  plethoric  patients  improve  upon  a  purely  vegetable  regimen.  In 
severe  cases  it  will  be  best  to  order  a  bread-and-milk  diet  for  a 
week  or  longer.  Vegetable  food  may  then  be  added,  but  sweets  and 
meats  should  be  withheld.  On  the  contrary,  feeble,  anaemic  patients 
usually  improve  upon  an  animal  diet,  consisting  largely  of  milk,  with 
eggs,  beef,  and  mutton.  Bread  may  be  allowed.  Elaborately  cooked 
and  highly  seasoned  food  is  forbidden,  as  well  as  all  forms  of  malt 
liquors.  If  any  alcohol  is  required  it  should  be  prescribed  in  the 
form  of  well-diluted  whisky  and  taken  only  with  meals,  but  as  a  rule 
patients  are  better  without  it. 

PRURITUS 

Patients  suffering  from  pruritus  should  partake  only  of  non-stim- 
ulating food.  They  should  temporarily  adopt  vegetarianism,  give  up 
all  meats  and  drink  abundant  water.  They  should  particularly  avoid 
tea,  coffee,  alcoholic  drinks  of  every  variety,  condiments,  pastry, 
cheese,  sauces,  sweets,  pastry,  preserves,  canned  foods,  pickles,  made 
dishes,  and  fried  food.  Tobacco  should  be  withheld. 


FURUNCULOSIS  —  OBESITY  691 

FURUNCULOSIS,  OR  BOILS 

Furunculosis  is  often  wrongly  attributed  to  dietetic  errors  or  high 
living,  but  it  is  now  known  to  be  of  germ  origin  due  to  the  action  of 
the  Staphylococcus  pyogenes  and  other  microorganisms  which  pene- 
trate the  skin,  through  abrasions  or  otherwise,  so  that  the  supposed 
influence  of  diet  is  only  remote,  in  that  poor  living  tends  to  lower 
the  general  vitality  and  make  the  body  more  susceptible  to  any  form 
of  inoculation.  Special  dietetic  treatment  becomes  necessary  only  in 
debilitated  cases,  such  as  complicate  anemia,  diabetes,  or  convales- 
cence from  protracted  infectious  diseases,  and  the  rules  for  it  will  be 
found  under  those  headings  (pp.  472,  539,  740). 

DISEASES   ESPECIALLY  INFLUENCED   BY   DIET 
OBESITY  (CORPULENCY,  POLYSARCIA) 

Causation. —  Obesity  is  a  diseased  condition  of  the  body,  depending 
"upon  alteration  in  the  proper  balance  of  nutrition,  with  an  accumula- 
tion of  fat  in  and  between  the  tissues.  This  lack  of  equilibrium  theo- 
retically may  be  due  to  (1)  excessive  ingestion  of  food  with  dimin- 
ished exercise.  (2)  Lowered  oxidation  activity.  (3)  Retardation 
of  normal  metabolic  activities. 

Obesity  may  affect  either  sex,  but  is  much  more  common  among 
Tvomen,  in  whom  it  is  particularly  noticed  during  and  after  the  cli- 
macteric. 

It  may  develop  at  any  age  after  early  childhood.  When  appear- 
ing early  it  is  usually  the  immediate  result  of  heredity.  It  is,  how- 
ever, most  common  soon  after  the  fortieth  year,  when  the  functional 
activity  of  the  body  is  diminished  and  when  habits  of  systematic  exer- 
cise are  replaced  by  a  sedentary  life  of  luxury  and  ease,  combined  with 
overeating. 

Aside  from  heredity,  an  important  cause  of  obesity  is  excessive  eat- 
ing, which  is  a  fault  among  many  persons  who  have  entered  middle 
life.  When  the  growth  of  the  body  has  been  completed  there  is  a 
stage  of  equilibrium  in  weight  which  lasts  for  several  years,  and  the 
waste  matter  of  any  excessive  food*  taken  is  eliminated  through  the 
emunctories  which  are  kept  active  by  exercise  and  work.  After  middle 
age,  activity  is  considerably  diminished,  while  the  habit  of  fully  satis- 
fying a  vigorous  appetite  may  be  continued,  resulting  in  the  consump- 
tion of  a  larger  amount  of  food  than  is  required  for  maintaining  the 
yital  functions.  It  is  extremely  difficult  for  people  who  feel  in  robust 
health  and  whose  mental  is  proportionately  greater  than  their  physical 


692          DISEASES  ESPECIALLY   INFLUENCED  BY  DIET 

activity,  to  realize  that  they  not  only  require  less  food  than  they  did 
ten,  fifteen,  or  twenty  years  earlier  in  life,  but  that  eating  as  they  do 
they  may  be  producing  positive  harm  by  overloading  the  excretory 
organs.  It  is  for  this  reason  that  many  persons  accumulate  weight 
after  reaching  an  advanced  period  of  life. 

According  to  Sir  Henry  Thompson's  view,  overeating  in  the  first 
half  or  so  of  life  may  be  relieved  by  occasional  bilious  attacks,  which 
enable  the  system  to  cast  off  accumulated  waste,  but  later  "the  un- 
employed material  may  be  relegated  in  the  form  of  fat  to  be  stored 
on  the  external  surface  of  the  body  or  be  packed  among  the  internal 
organs,  and  thus  he  or  she  may  become  corpulent  and  heavy ." 

The  constant  use  of  alcoholic  stimulation  in  its  milder  forms,  such 
as  beer  and  ale,  favors  obesity,  and  in  many  persons  seems  to  be  a 
direct  cause  of  it.  There  are  other  cases  in  which  it  is  difficult  to 
attribute  the  accumulation  of  fat  to  any  faults  in  either  eating  or 
drinking.  Very  stout  persons  are  occasionally  extremely  moderate 
eaters,  and  in  these  cases  the  difficulty  lies  apparently  in  poor  oxida- 
tion and  insufficient  exercise. 

The  condition  of  obesity  is  somewhat  modified  by  climate  and  race. 
It  is  less  common  in  the  United  States  than  it  is  among  elderly 
women  in  England  and  Germany. 

Not  infrequently  obesity  occurs  in  connection  with  pronounced 
anaemia  and  hysteria.  It  prevents  such  patients  from  taking  an  ordi- 
nary amount  of  exercise.  This  is  owing  to  the  increased  weight  and 
difficulty  of  moving  about,  as  well  as  to  the  lassitude  and  positive  dis- 
like for  muscular  exertion  which  is  felt  by  them.  Obesity  once 
established  is  likely  to  increase  unless  properly  treated. 

So  long  as  the  fat  is  simply  stored  up  as  adipose  tissue,  and  be- 
tween and  not  within  the  cellular  elements  of  the  body,  it  is  compara- 
tively harmless,  excepting  as  it  indicates  a  disproportion  between 
functional  activity  and  the  amount  of  fuel  taken  to  develop  force, 
and  excepting  also  as  it  may  interfere  with  personal  convenience  in 
movement  and  cause  greater  muscular  fatigue  from  the  increased 
work  thrown  upon  the  muscles  in  supporting  so  heavy  a  body.  In 
other  cases  (and  this  may  be  the  outcome  of  any  advanced  case  of 
polysarcia)  the  fat  may  invade  the  cellular  elements  of  the  body, 
particularly,  the  muscles,  and  fatty  degeneration  is  produced  in  the 
muscular  tissues,  which  very  seriously  weakens  and  impairs  their 
functional  activity.  The  special  danger  in  all  cases  of  this  class  is 
that  the  heart  muscle  may  become  affected  in  this  manner,  which 
renders  it  liable  to  cease  beating  whenever  the  slightest  additional 
strain  is  thrown  upon  the  circulation.  It  follows  that  it  is  most  de- 


OBESITY  693 

sirable  in  the  dietetic  treatment  of  obesity  to  determine  the  original 
cause  of  fat  accumulation,  and  to  ascertain  to  what  extent  it  is  ac- 
companied by  fatty  degeneration.  Suppose  a  woman  to  weigh  120 
pounds  at  20  years  of  age  and  240  at  40  years.  In  doubling  the 
size  of  the  body  she  has  the  same  sized  heart  to  maintain  the  circula- 
tion, that  she  had  at  20  years,  but  it  has  much  more  work  to  do,  for 
every  time  she  walks  or  climbs  a  flight  of  stairs,  she  raises  the  addi- 
tional 120  Ibs.  of  dead  weight. 

Bauer  says :  "  The  fat  stored  up  in  the  body  acts  in  like  manner 
with  the  fat  contained  in  the  food,  since  it  likewise  lessens  the  waste 
of  tissue  and  secondarily  the  oxidation.  Thus  we  understand  why 
abstinence  can  be  longer  borne  by  organisms  rich  in  fat  than  by 
those  poorly  furnished  with  it,  the  former  consuming  less  of  the 
albumin  of  their  organs.  The  stock  of  fat  stored  in  the  body  is 
moreover  the  cause  that  corpulent  individuals  frequently  continue  to 
gain  in  bulk  although  they  are  not  in  the  habit  of  indulging  in  food 
immoderately. 

"  If  an  increase  of  albumin  be  desired  without  a  considerable  addi- 
tion to  the  store  of  fat,  a  liberal  allowance  of  albumin  with  relatively 
small  quantities  of  carbohydrates  must  be  provided.  If,  on  the  other 
hand,  a  substantial  addition  to  the  fat  appear  desirable,  the  food  must 
contain  less  albumin  and  more  carbohydrates,  with  a  fair  proportion 
of  fats/' 

Voit  claims  that  albumin  circulating  in  the  blood  is  more  readily 
oxidized  than  either  fats  or  carbohydrates,  and  that  the  fat  existing 
in  the  tissues  acts  like  free  circulating  fat,  not  primarily  by  saving 
proteids  from  oxidation,  but  by  causing  a  larger  proportion  of  them 
to  enter  into  the  organized  tissues,  thus  saving  tissue  waste.  The 
tissues  use  up  the  circulating  albumin,  and,  not  being  exhausted 
thereby,  go  on  and  oxidize  the  fat  besides,  and  in  this  manner  the 
store  of  fat  in  the  body  is  reduced  on  a  meat  diet. 

An  exclusive  lean-meat  diet  increases  the  circulating  albumin,  and, 
the  nitrogenous  waste  being  correspondingly  increased,  fat  does  not 
accumulate  in  the  body.  If  now  fat  be  added  to  the  diet,  fat  is 
deposited  in  the  body. 

The  carbohydrates,  like  fat,  can  protect  circulating  albumin  from 
katabolism  and  aid  its  transformation  to  organic  albumin,  but  it  is 
not  proved  that  they  themselves  make,  fat,  as  at  first  supposed,  for 
they  are  very  completely  destroyed  even  when  eaten  in  excess.  They 
merely  protect  other  foods  from  oxidation  under  such  conditions. 

Meat  and  carbohydrates  alone  increase  the  fat  in  the  body  with- 
out the  aid  of  fatty  food,  for  fat,  which  originates  from  splitting  up 


694         DISEASES  ESPECIALLY  INFLUENCED   BY  DIET 

albumin,  is  spared  further  metabolism.  Hence  fatty  metabolism  in 
the  body  may  be  quite  independent  of  fat  ingestion. 

It  has  lately  been  shown  that  fluctuations  in  body  weight  are 
largely  dependent  upon  the  gain  or  loss  of  water  temporarily  stored 
in  the  tissues  and  fluids  of  the  body.  A.  Gouin  and  P.  Andouard 
proved  that  animal  tissues  tend  to  store  water  when  a  sugar  diet  is 
employed.  Weighing  the  body  does  not  demonstrate  the  true  gain 
or  loss  in  either  fat,  proteid  or  carbohydrate.  Benedict  and  Milner  in 
a  comparative  study  of  a  fat  and  a  carbohydrate  diet,  each  with 
4,500  grams  of  water  a  day,  found  that  on  a  carbohydrate  diet,  a 
man  gained  61.3  grams  a  day  in  weight,  but  lost  weight  on  a  fat  diet, 
though  both  diets  furnished  the  same  amount  of  energy  —  69  calories 
more  heat  were  developed  on  the  fat  diet.  A  transition  from  the 
carbohydrate  to  the  fat  diet  caused  a  marked  loss  of  water  from  the 
body. 

Although  the  metabolism  resulting  in  obesity  is  probably  substan- 
tially the  same  in  all  eases,  it  is  nevertheless  convenient  to  recognize 
several  clinical  types,  differing  somewhat  in  the  possible  results  of 
treatment.  These  may  be  grouped  as  follows : 

I.  Obesity  in  children  and  youth,  often  hereditary.     In  these  casea 
reduction  treatment  should  be  intermittent  in  order  not  to  limit  nor- 
mal growth  and  development. 

II.  Moderate  obesity  in  the  middle-aged,  capable  of  being  held  in 
check  by  periodical  reduction  cures.     Such  patients  weigh  20  to  30 
Ibs.  more  than  the  normal  average. 

III.  More  obstinate  cases,  tending  to  excessive  corpulency  and  re- 
quiring constant  treatment.     Such  patients  may  weigh  30  to  60  Ibs. 
more  than  the  normal  average. 

IV.  Cases  of  extreme  obesity,  patients  weighing  250  to  400  Ibs. 
or  more,  in  which  reduction  treatment  is  not  always  safe,  and  seldom 
is  even  partially  successful. 

Dietetic  Treatment 

The  question  of  the  treatment  of  obesity,  owing  to  the  frequency 
with  which  the  physician  has  to  deal  with  it,  is  a  matter  of  great 
importance,  and  demands  special  consideration.  The  best  results 
from  treatment  are  obtained  in  patients  less  than  thirty  years  of  age. 
For  a  long  time  it  was  believed  that  excessive  consumption  of  carbo- 
hydrates was  the  cause  of  increased  fat  production  within  the  body. 
The  pig  is  fattened  on  corn,  and  cattle  upon  various  cereals.  Un- 
doubtedly many  persons  who  are  of  spare  habit  can  increase  their 
weight  by  eating  a  larger  proportion  of  starches  and  sugars.  It  is  a 


OBESITY  695 

fact,  moreover,  that  starches  contain  oxygen  in  the  exact  proportion 
necessary  for  the  formation  of  water  and  carbon  dioxide,  and  on  be- 
ing disintegrated  in  the  body,  they  naturally  produce  these  two  forms 
of  waste  matter  which  are  promptly  eliminated  from  the  surface  of 
the  lungs  and  kidneys  respectively.  The  proteid  material  of  the  food 
requires  a  larger  percentage  of  oxygen  for  the  metabolism  involved  in 
its  complete  conversion  into  urea. 

It  is  an  undoubted  physiological  fact  that  the  fat  of  the  body  may 
be  made  from  a  variety  of  different  foods,  and  that  some  persons  are 
capable  of  producing  it  from  a  particular  class  of  food  materials  more 
readily  than  from  others.  Thus  one  may  become  fat  from  over- 
indulgence in  saccharine  food  and  another  from  eating  purely  starchy 
foods  and  taking  large  quantities  of  malt  and  beer,  and  another 
from  the  excessive  use  of  quantities  of  fat  meat.  Accordingly  the 
rules  which  are  formulated  for  the  treatment  of  obesity  should  be 
regarded  as  referring  to  the  majority  of  cases  only,  whereas  there  are 
many  exceptions  to  be  individually  studied. 

Many  special  dietetic  systems  are  in  vogue  for  the  treatment  of 
obesity.  In  some  cases  if  the  total  quantity  of  food  is  diminished  no 
special  diet  is  necessary,  but  in  many  persons  obesity  is  not  solely  due 
to  overeating,  but  to  other  causes.  Some  patients  improve  at  once 
when  they  give  up  all  alcoholic  beverages.  An  ounce  of  food  eaten 
daily  in  excess  of  that  which  is  eliminated,  and  which  is  capable  of 
being  stored  in  the  tissues  in  the  form  of  fat,  very  soon  produces  a 
considerable  increase  in  the  body  weight,  which  in  a  year's  time  would 
amount  to  many  pounds. 

As  stated  above,  the  majority  of  the  obese  eat  too  much  and  exer- 
cise too  little,  or  at  least  they  have  originally  eaten  more  than  they 
consumed,  i.  e.,  although  they  may  delude  themselves  to  the  contrary 
and  claim  to  be  small  eaters,  they  have  at  some  period  consumed  too 
many  calories,  hence  it  makes  little  difference  whether  the  curative 
diet  be  restricted  in  fats  or  in  carbohydrates,  so  long  as  the  total 
caloric  energy  be  cut  down.  As  pointed  out  by  von  Xoorden,  the 
detailed  mode  of  restriction  may  be  left  in  great  part  to  the  individual 
patient's  liking,  so  long  as  the  general  principles  are  adhered  to  of 
reduction  in  quantity  of  food  and  increase  in  oxidation  by  exercise 
and  outdoor  air.  As  a  general  statement,  from  one  to  two-fifths  should 
represent  the  degree  of  reduction  in  quantity  of  food  in  an  average 
case,  and  in  general  this  may  be  accomplished  by  eliminating  sugars 
and  alcohol  in  toto  and  reducing  to  a  minimum  the  consumption  of 
fats  and  of  bread,  potatoes,  cereals,  and  other  forms  of  starch. 

Among  the  different  systems  which  have  been  advocated  for  the 


696         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

cure  of  obesity  the  best  known  are  those  of  Banting,  Ebstein,  and 
Oertel.  Schweninger's  cure  is  practically  Oertel's  method  by  with- 
holding fluid  from  the  meals,  and  giving  all  fluid  at  least  two  hours 
after  ingestion  of  food.  Schleicher's  system  is  also  similar  to  Oertel's. 

The  principal  systems  which  have  been  devised  especially  for  the 
treatment  of  obesity  will  be  separately  discussed  in  detail.  Nearly 
all  of  these  systems  agree  in  two  principles:  First,  to  reduce  the 
total  quantity  of  food  ingested  as  much  as  possible  without  impair- 
ing the  strength  of  the  patient.  Second,  to  diminish  the  quantity  of 
fluid  drunk  by  prescribing  what  is  called  a  dry  diet.  The  treatment, 
moreover,  is  usually  accompanied  by  systematic  exercise  and  bathing, 
and  it  is  important  to  keep  the  bowels  active. 

The  attempt  is  sometimes  made  to  cure  obesity  by  allowing  the  pa- 
tient to  eat  any  food  he  chooses,  but  insisting  that  he  shall  eat  only 
one  kind  of  food  at  any  one  meal.  As  a  natural  result,  the  appetite 
soon  palls,  and  he  eats  less  than  he  otherwise  would.  This  is  an  un- 
scientific method,  and  an  unwholesome  one  for  serious  cases. 

Patients  should  acquire  the  habit  of  slow  eating,  which  tends  to 
lessen  the  amount  of  food  taken. 

As  a  general  principle,  corpulent  persons  should  restrain  them- 
selves to  as  great  an  extent  as  possible  from  drinking  fluids,  espe- 
cially with  meals.  Exceptions  to  this  rule  occur  when  obesity  com- 
plicates certain  other  diseases,  such  as  gout  or  rheumatism,  where 
the  use  of  an  increased  quantity  of  fluid  may  be  temporarily  neces- 
sary in  order  to  act  vigorously  upon  the  kidneys. 

Hot-water  beverages  taken  half  an  hour  before  meals,  and  again 
at  night  and  on  rising  in  the  morning,  are  beneficial,  and  less  fluid 
is  required  with  the  meals.  Never  more  than  five  ounces  of  fluid  of 
any  sort  should  be  taken  with  a  meal,  or  fifteen  ounces  per  diem,  and 
tli is  measure  may  be  further  curtailed  by  giving  water  between  meals 
instead. 

Soups  of  all  kinds  should  be  forbidden  as  well  as  alcoholic  bev- 
erages, and  what  little  fluid  is  allowed  should  consist  of  plain  or 
aerated  water.  Little,  if  any,  milk  should  be  taken.  The  food 
should  be  as  dry  as  possible  without  interfering  with  its  flavor  and 
nutrient  value.  Highly  succulent  fruits,  such  as  watermelons,  and 
vegetables  like  raw  tomatoes,  which  consist  largely  of  water,  should 
not  be  eaten.  S\igar  should  be  forbidden  absolutely,  and  fat  should 
be  used  very  sparingly,  and  only  in  the  form  of  a  little  butter.  The 
allowance  of  farinaceous  food  should  also  be  cut  down  as  much  as 
possible.  Tt  will  not  usually  be  found  practicable  to  do  without  bread 
for  any  length  of  time,  but  patients  are  often  willing  to  restrict  them- 


OBESITY  697 

selves  to  a  very  strict  diet  for  two  or  three  weeks  if  the  positive  hope 
of  cure  or  amelioration  of  symptoms  may  be  held  out  to  them,  if  they 
are  made  to  understand  the  rationale  of  the  treatment,  and  if  they 
are  given  some  objective  point  to  anticipate  when  a  promised  improve- 
ment will  admit  of  greater  laxity  in  regard  to  diet.  If  desirable, 
gluten  bread  may  be  substituted  for  wheaten  bread. 

The  deprivation  of  starchy  foods  can  always  be  better  and  longer 
tolerated  if  a  little  fat  be  given,  and  the  obese  do  not  endure  well 
deprivation  of  all  fats,  even  when  farinaceous  food  is  supplied  in 
moderation. 

This  is  often  more  true  of  those  engaged  in  mental  work  than  of 
those  employed  in  muscular  exercise.  Fresh  fruit  and  fresh  green 
vegetables — "vegetables  which  grow  above  the  ground,"  except  the 
legumes  and  corn  —  should  not  be  withheld. 

Lean  meat  should  form  the  basis  of  all  diet,  but  an  unrestricted 
flesh  diet  in  obesity  may  give  rise  to  dyspepsia  and  gastric  and  intes- 
tinal catarrh. 

THE  BANTING  SYSTEM 

The  diet  which  Mr.  Banting  practiced  upon  himself  in  1862  with 
considerable  success,  and  which  bears  his  name,  was  exceedingly  strict 
in  regard  to  diminishing  the  quantity  of  food  and  forbidding  starches 
and  sugars  to  the  greatest  degree  possible.  The  patients  were  starved 
to  the  extent  of  being  allowed  only  between  twenty-one  and  twenty- 
seven  ounces  of  dry  food  in  the  twenty-four  hours,  about  one-half  of 
which  was  meat.  Only  two  ounces  of  bread  could  be  taken,  and  the 
balance  of  the  diet  was  composed  of  fresh  fruits  and  the  lighter  forms 
of  green  vegetables.  The  fluid  drunk  in  each  twenty-four  hours  was 
reduced  to  thirty-five  ounces.  It  should  be  remembered  that  the 
normal  quantity  of  urine  passed  by  an  adult  is,  on  the  average,  fifty- 
two  ounces  in  addition  to  the  water  lost  by  perspiration  and  respira- 
tion. In  his  dietary,  which  was  based  on  the  suggestions  of  Dr.  Wil- 
liam Harvey,  the  fats  and  albuminoids  are  not  well  balanced,  and  it 
may  cause  constipation  and  malnutrition. 

THE   EBSTEIN  SYSTEM 

The  Ebstein  treatment,  as  originally  employed  in  Germany,  has 
been  attended  with  considerable  success.  The  theory  of  this  system 
(which  in  part  accords  with  that  stated  on  page  693)  is  that  animal  as 
well  as  carbohydrate  food  is  capable  of  being  converted  into  fat,  espe- 
cially when  used  in  combination  with  starches  and  sugars.  The  latter 
are  believed  to  furnish  force  for  the  body,  and  by  their  combustion 


€98 


DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 


to  spare  the  complete  oxidation  of  albuminates,  which  are  therefore 
stored  in  the  tissues  in  a  suboxidized  form.  It  is  a  part  of  this  theory 
that  fatty  food  does  not  give  rise  to  or  promote  the  storage  of  fat  in 
the  body,  and  hence  it  may  be  allowed  in  the  dietary ;  in  fact,  Ebstein 
recommends  its  use  on  account  of  its  effect  in  producing  satiety.  By 
sooner  diminishing  the  appetite,  there  is  less  craving  for  other  food 
and  drink.  In  accordance  with  this  belief,  he  proscribes  the  use  of 
sugar,  potatoes,  and  all  forms  of  farinaceous  food  with  the  exception 
of  three  ounces  and  a  half  of  bread,  which  is  allowed  each  day.  He 
permits  the  use  of  fats,  such  as  fat  meat,  cream,  butter,  and  fatty 
soups.  Among  vegetables  he  allows  asparagus,  spinach,  cabbage,  peas, 
and  beans.  A  moderate  amount  of  meat  of  any  kind  is  also  included. 
The  quantity  of  fluids  allowed  is  restricted.  The  patient  is  permitted 
to  take  three  meals  a  day. 

Breakfast  consists  of  a  cup  of  black  tea  without  sugar  or  milk 
and  two  ounces  of  buttered  toast. 

Dinner,  which  is  given  at  noon,  comprises  a  meat  soup  or  broth, 
four  to  six  ounces  of  boiled  or  roasted  fat  beef  with  meat  gravy,  not 
thickened,  one  or  two  fresh  vegetables,  in  moderation,  and  for  des- 
sert salads  and  fresh  or  dried  fruits.  A  little  light  wine  and  black  tea 
without  milk  or  sugar  may  be  drunk. 

Supper  includes  tea  as  before,  a  soft-cooked  egg  and  a  moderate 
allowance  of  fish,  ham,  or  cold  fat  meat,  an  ounce  of  thin  buttered 
bread  or  toast,  and  fresh  fruit. 

Comparison  of  Dietaries  for  Corpulence  with  Ordinary  Dietaries  (Atwater). 


DIETARIES. 

NUTRIENTS. 

Potential 
energy  in 
nutrients. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total 

Grams. 
171 
102 

57 
119 
118 
100 
125 
53 
100 
128 

Grams. 
8 
85 

14 
51 
56 
100 
125 
33 
100 
177 

Grams. 
75 
47 

341 
531 
500 
360 
450 
316 
240 
466 

Grams. 

254 
234 

412 

701 
674 
560 
700 
402 
440 
771 

Calories. 

1,085 
1,400 

1,760 
3,140 
3,050 
2,815 
3,520 
1,820 
2,325 
4,080 

Plavfair's  standard  for  "  subsistence 
d'iet  "                                        

Playfair's  standard  for  adults  with 

Voit's    standard    for    laboring    man 
at  moderate  work    

Atkinson's   standard    for   man   with 
lifht  exorcise      

Atkinson's     standard     for     laboring 
man  at  moderate  work   

Poor     sewing     girl,     London;     diet 
barely  sufficient  for  subsistence  .  . 
University  professor,  Germany;  very 
light  exercise   

Well-to-do  family.  Connecticut  ;  food 
actually  eaten    

OBESITY 


699 


Comparison  of  Dietaries  for  Corpulence  with  Ordinary  Dietaries   (Atwater). — 
Continued. 


NUTRIENTS. 

DIETARIES. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

energy  in 
nutrients. 

Grams. 

Grams. 

Gtams. 

Grams. 

Calories. 

Mechanics    and    factory    operatives, 

Massachusetts  ;  food  purchased  .  . 

127 

186 

531 

844 

4,430 

Food  actually  eaten  by  college  stu- 

dents : 

From  Northern  United  States  .  .  . 

138 

184 

622 

944 

4,825 

From  Eastern  United  States  .... 

104 

136 

421 

661 

3,415 

THE  OERTEL  SYSTEM 

Another  system  for  the  dietetic  treatment  of  obesity  is  that  prac- 
ticed by  Oertel  and  modified  by  Schweninger  (who  prescribed  it  for 
Bismarck  with  benefit).  The  distinctive  feature  of  the  Oertel  treat- 
ment is  the  attention  which  is  paid  to  improving  the  condition  of  the 
circulation  by  strengthening  the  heart  action,  and  this,  he  claims,  so 
much  improves  the  general  condition  of  the  patient  that  the  fat  once 
eliminated  is  not  reformed.  According  to  his  theory,  corpulent  pa- 
tients may  be  subdivided  into  two  different  classes,  whose  diet  is  regu- 
lated accordingly.  They  are: 

"  (a)  Cases  of  fat  accumulation  in  which  the  respiratory  and  cir- 
culatory apparatus  have  undergone  no  special  derangement,  and  the 
patient  is  capable  of  muscular  effort  and  locomotion.  A  much  more 
serious  form  is  that  in  which  the  condition  of  fatty  heart  is  present, 
with  consequent  enfeeblement  of  circulation  and  visceral  engorgement. 

"  (6)  Cases  in  which,  in  consequence  of  advanced  stasis  and 
hydraemia  (with  deficiency  of  haemoglobin),  the  amount  of  oxygen 
taken  up  from  the  lungs  is  extremely  reduced,  and  the  slightest 
muscular  efforts  are  enough  to  disturb  the  respiration  and  provoke 
dyspnoea." 

For  the  first  class  his  maximum  allowance  of  fat  is  50  grams  and 
of  carbohydrates  200  grams,  with  a  minimum  of  150  grams  of  albu- 
min. For  the  second  class  the  maximum  allowance  of  fat  is  25-30 
grams,  with  100  grams  of  carbohydrates,  but  the  albumin  must  con- 
siderably exceed  150  grams.  In  this  class  especially  the  amount  of 
fluids  drunk  is  curtailed.  By  withholding  fluid,  Oertel  argues,  blood 
pressure  is  reduced,  venous  stasis  is  lessened,  the  vessels  of  the  body 
will  adapt  themselves  to  the  reduced  quantity  of  fluid,  and  to  supply 
the  glandular  organs  and  muscles  with  their  normal  proportion  fluid 
will  be  "  drained  away  from  places  where  the  tissue  changes  are  less 
energetic,  and  which  are  less  favorably  innervated.  Such  vessels  are, 


700          DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

above  all,  in  the  fatty  tissues  —  vessels  branching  in  the  panniculus 
adiposus."  Nutritive  changes  ensue  in  the  fatty  tissues,  the  fat  is 
disintegrated,  conveyed  away,  and  burned  up. 

This  is  certainly  an  ingenious  and  withal  very  plausible  theory 
which  has  many  facts  of  clinical  observation  to  recommend  it. 

Besides  holding  the  view  that  the  fluid  in  the  body  must  be  re- 
duced before  the  accumulated  fat  can  be  diminished,  Oertel  says: 
"  Since  the  force  required  to  raise  the  body  through  a  great  height 
entails  the  destruction  of  large  quantities  of  fat,  the  above  exertion 
[graduated  hill  climbing]  will  also  lessen  the  fat  accumulation,  on 
condition  only  that  we  give  less  fat  and  carbohydrates  in  the  food 
than  are  used  up  in  the  work  done." 

He  gives  some  fat  and  carbohydrate  food,  but  not  very  much,  with 
proteids,  for  he  believes  that,  anaemia  being  present,  an  exclusive  meat 
diet  would  not  be  completely  oxidized.  It  is  better,  therefore,  to 
restrict  all  three  classes  of  foods,  but  not  entirely  to  exclude  either, 
and  the  proteids  must  decidedly  preponderate. 

He  also  believes  that  anaemia  weakens  the  vascular  tone  through 
supplying  a  blood  deficient  in  circulating  albumin,  and  hence  a  diet 
rich  in  proteids  is  further  indicated. 

The  Oertel  system  includes  almost  twice  the  quantity  of  animal 
food  allowed  in  the  Ebstein  diet,  and  double  the  quantity  of  carbo- 
hydrates and  less  than  half  the  quantity  of  fats.  It  is  distinguished 
from  the  Banting  system  also  by  the  greater  preponderance  of  fats 
and  starches. 

The  more  liberal  dietary  of  Oertel  is  particularly  suitable  for  those 
cases  in  which  exercise  can  supplement  dietetic  treatment.  The  com- 
bined effect  of  the  diet  with  exercise  results  in  the  absorption  and 
oxidation  of  the  fat  deposited  between  the  muscular  tissues  and  in 
the  renewal  of  more  vigorous  action  of  the  muscle  fibers,  which  are 
shielded  from  waste  by  the  liberal  proportion  of  proteid  food  which 
is  admitted.  The  whole  treatment  is  aimed  especially  at  increasing 
the  vigor  and  force  of  the  heart  action,  and  in  many  cases  it  suc- 
ceeds admirably.  In  the  more  serious  type  of  obesity  the  deposition 
of  fat  around  the  base  of  the  heart  as  well  as  between  and  within 
the  heart  muscle  fibers  enfeebles  the  strength  of  the  cardiac  systole 
and  results  in  engorgement  of  the  venous  circulation.  Lack  of  exer- 
cise also  retards  the  venous  circulation.  As  a  result,  there  is  a  con- 
stant venous  congestion  which  is  particularly  noticeable  in  the  viscera, 
and  there  may  be  dropsical  accumulations  in  the  different  serous 
cavities  or  general  anasarca. 

Anaemia  is  believed  to  be  counteracted  bv  the  use  of  albuminous 


OBESITY  701 

food,  and  the  following  articles  are  allowed  when  this  is  a  prominent 
symptom:  Lean  roast  and  boiled  beef  and  veal,  mutton,  game,  and 
eggs.  Vegetables,  spinach,  and  cabbage  may  be  eaten.  From  four 
to  six  ounces  of  bread  per  diem  are  given,  and  fats  and  starches  are 
restricted  as  much  as  possible,  and  sugars  are  withheld  altogether. 
The  fluid  prescribed  consists  of  a  moderate  cup  (about  six  ounces) 
of  coffee  or  tea  or  milk  twice  a  day,  with  twelve  ounces  of  wine  with 
an  equal  quantity  of  water,  which  may  be  taken  at  dinner.  If  pa- 
tients perspire  very  freely,  a  somewhat  larger  quantity  may  be  given, 
and  no  other  beverages  of  any  kind  are  permitted. 

The  fluid  allowed  should  not  all  be  taken  with  the  meals,  but  may 
be  drunk  at  intervals  between  the  times  of  eating  to  allay  thirst.  In 
the  less  serious  type  of  cases,  where  the  heart  action  is  unimpaired, 
Oertel  allows  the  fluid  to  be  gradually  increased,  and  he  gives  four  to 
six  ounces  of  wine  at  noon  time,  with  a  half  bottle  in  the  evening. 

Exercise. —  Oertel  withholds  fluid  from  the  diet  as  much  as  possible, 
and  to  assist  the  elimination  of  water  from  the  body  the  patient  is 
made  to  exercise  by  climbing  carefully  graded  paths,  which  are  meas- 
ured and  adapted  with  reference  to  use  by  patients  of  different 
strength.  During  muscular  exertion  the  destruction  of  non-nitrog- 
enous foodstuffs  is  increased. 

This  exercise  by  climbing  ascents  is  sometimes  called  the  "  terrain 
cure/' 

In  case  the  patient  is  unable  to  exercise  at  all,  the  object  is  at- 
tained by  massage,  passive  or  "  resisted  "  movements  and  friction,  and 
the  promotion  of  perspiration  is  secured  by  baths  of  different  sorts. 
In  the  treatment  of  such  cases,  among  the  solid  ingredients  of  the 
food,  the  fats  and  starches  are  still  further  reduced. 

Bathing  should  be  carried  out  systematically,  and  the  patient  may 
be  packed  with  cloths  dipped  in  hot  water  in  order  to  promote  per- 
spiration. The  baths  are  given  at  least  twice  a  week  through  a  period 
of  a  month  or  more. 

A  typical  menu  under  the  Oertel  treatment  is  the  following: 

Oertel' s   Diet   for   Obesity 

"  Morning. —  One  cup  of  coffee  or  tea,  with  a  little  milk  —  alto- 
gether about  six  ounces ;  bread  about  three  ounces. 

"Noon. —  Three  to  four  ounces  of  soup,  seven  to  eight  ounces  of 
roast  or  boiled  beef,  veal,  game,  or  not  too  fat  poultry,  salad  or  a 
light  vegetable,  a  little  fish  (cooked  without  fat),  if  desired,  one 
ounce  of  bread  or  farinaceous  pudding  (never  more  than  three 
ounces),  three  to  six  ounces  of  fruit,  fresh  preferred,  for  dessert.  It 


702          DISEASES  ESPECIALLY  INFLUENCED  BY   DIET 

is  desirable  at  this  meal  to  avoid  taking  fluids,  but  in  hot  weather  or 
in  the  absence  of  fruit,  six  to  eight  ounces  of  light  wine  may  be 
taken. 

"  Afternoon. —  The  same  amount  of  coffee  or  tea  as  in  the  morning, 
with  at  most  six  ounces  of  water,  and  an  ounce  of  bread  as  an  ex- 
ceptional indulgence. 

"  Evening. —  One  or  two  soft-boiled  eggs,  an  ounce  of  bread,  per- 
haps a  small  slice  of  cheese;  salad  and  fruit,  six  to  eight  ounces  of 
wine  with  four  or  five  ounces  of  water." 

(In  this  country  it  is  found  desirable  to  omit  wine,  as  well  as  other 
forms  of  alcohol.  Due  allowance  should  be  made  for  Continental 
habits.) 

After  patients  have  undergone  a  special  course  of  treatment  for 
obesity  and  their  weight  has  been  reduced  sufficiently,  it  is  desirable 
to  establish  a  diet  for  them  which  will  prevent  a  return  of  the  fat. 
For  this  purpose  Oertel  recommends  the  following  regimen;  it  is 
intended  for  patients  in  whom  obesity  has  complicated  organic  dis- 
ease of  the  heart  or  lungs : 

"  Morning. —  One  cup  of  coffee  or  tea  with  some  milk  =  150  grams 
(6  ounces),  and  bread  =  75  grams  (%y2  ounces). 

"Midday. —  Soup  =  100  grams  (3y2  ounces);  lean  meat,  roasted 
or  boiled,  game  or  fowl  =  200  grams  (7  ounces) ;  fish,  not  too  fat  = 
25  grams  (nearly  1  ounce) ;  bread  or  starch  stuffs  =  100  grams  at 
most  (3!/o  ounces) ;  as  dessert  100  to  200  grams  (3y2  to  7  ounces) 
of  fruit,  fresh  preferred  —  a  smaller  quantity  if  preserved,  especially 
by  Nagelis's  method.  Liquids  are  better  avoided.  At  dinner  time, 
only  in  very  hot  weather  or  in  the  absence  of  fruit,  perhaps  %  to  *4 
liter  of  light  wine  may  be  allowed  (6  to  9  ounces). 

"  Afternoon. —  The  same  quantity  of  coffee  or  tea  as  before,  with 
at  most  y6  liter  of  water  (6  ounces) ;  occasionally  25  grams  of  bread 
(nearly  1  ounce). 

"Evening. —  One  or  two  soft-boiled  eggs;  meat,  150  grams  (nearly 
5  ounces)  ;  bread,  25  grams  (nearly  1  ounce) ;  a  bit  of  cheese,  a  little 
salad  and  fruit.  As  a  regular  drink,  ye  to  %  liter  of  wine  (6  to  9 
ounces),  with  perhaps  %  liter  of  water  (4i/£>  ounces)." 

Water  should  never  be  allowed  in  quantity,  and  what  little  is 
drunk  should  be  distributed  through  the  day. 

THE   SCHWENINGEE  SYSTEM 

Schweninger's  system  is  essentially  that  of  Oertel,  but  the  former 
absolutely  forbids  the  use  of  drink  of  any  kind  with  meals,  and  the 
little  fluid  that  is  permitted  is  to  be  taken  fully  two  hours  afterwards. 


OBESITY  703 

His  treatment  is  substantially  as  follows:  Moderate  exercise  for 
an  hour  before  breakfast,  after  a  cold  bath  with  friction. 

Breakfast,  8  A.  M. —  Meat,  eggs,  or  milk.     A  walk. 

Second  Breakfast,  10.30  A.  M. —  Meat  or  fish  and  a  glass  of  white 
wine.  A  walk. 

Dinner,  1  p.  M. —  Meat,  vegetables,  and  fruit  compote. 

Supper,  7  p.  M. —  Meat  and  fruit  compote  or  salad,  a  glass  of  white 
wine. 

Xo  other  fluid  is  given  with  meals.     Bread  is  eaten  very  sparingly. 

THE  WEIR  MITCHELL  SYSTEM 

"Weir  Mitchell,  for  the  treatment  of  obesity,  relies  mainly  on  rest 
and  passive  exercise  in  the  form  of  massage  and  Swedish  move- 
ments with  a  skimmed-milk  diet,  which  latter  may  be  given  at  in- 
creasing rate,  gradually  replacing  the  accustomed  food,  until  in  a 
week's  time  the  patient  is  living  upon  milk  exclusively.  Upon  this, 
diet,  the  patient  may  lose  half  a  pound  or  more  in  weight  per  diem. 
Careful  watch  is  kept  of  the  strength.  The  patient  should  fre- 
quently be  examined  with  special  reference  to  loss  of  weight  and  to 
any  unfavorable  increase  in  the  heart  action  or  feebleness  of  the 
pulse.  If  the  latter  conditions  arise,  it  may  be  necessary  to  increase 
the  diet  or  to  give  stimulation.  A  small  quantity  of  beef,  chicken,  or 
oyster  soup  is  allowed  in  such  cases  to  relieve  the  monotony  of  an 
exclusive  milk  diet.  The  patient  is  kept  quiet  in  bed  for  ten  days 
or  a  fortnight,  and  afterwards  permitted  to  move  about  the  room, 
but  must  spend  most  of  his  time  upon  a  lounge.  Massage  is  per- 
formed once  or  twice  a  day  at  first,  and  subsequently  the  more  active 
Swedish  movements  are  applied  to  the  extremities.  After  from  four 
to  six  weeks  of  this  treatment  the  weight  is  usually  reduced  by  a  num- 
ber of  pounds,  and  the  general  condition  and  strength  are  found  to 
have  improved.  The  diet  is  gradually  increased  by  the  addition  of 
lean  meats,  beef,  mutton,  poultry,  shellfish,  and  boiled  fish.  For  a 
long  time,  however,  milk  plays  an  important  role,  four  or  -five  glasses 
being  taken  daily. 

Weir  Mitchell  argues  that  so  sudden  a  loss  of  weight  as  occurs 
in  his  treatment  would  be  serious  were  the  patient  walking  about, 
but  when  resting  quietly  in  bed  the  danger  of  sudden  exhaustion 
of  the  heart  action  is  reduced  to  a  minimum. 

THE  YEO  SYSTEM 

The  diet  recommended  by  Yeo  is  as  follows :  All  fats  and  animal 
food  are  to  be  limited  strictly,  and  farinaceous  and  starchy  foods 


704         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

should  be  reduced  to  a  minimum.  Sugar  must  be  prohibited  entirely, 
but  a  moderate  quantity  of  fat  is  allowed  to  secure  the  proper  dilu- 
tion and  digestion  of  the  food.  Hot  water  and  hot  aromatic  drinks 
may  be  taken  freely  in  the  intervals  between  meals,  especially  in 
gouty  cases.  He  allows  the  patient  to  drink  a  little  hock  and  still 
Moselle,  or  light  claret  with  alkaline  table  water.  Beer,  porter,  and 
sweets  of  all  kinds  are  prohibited,  and  no  spirits  should  be  drunk 
unless  for  some  special  need  as  a  tonic.  Meat  is  not  to  be  eaten  more 
than  once  a  day,  and  not  more  than  six  ounces  should  be  taken  at  any 
one  time.  The  meat  which  Yeo  allows  is  lean  beef,  mutton,  lamb, 
poultry,  game,  and  sometimes  fish  and  eggs.  Two  lightly  cooked  or 
poached  eggs  may  be  taken  once  a  day,  or  a  little  grilled  fish.  He 
allows  thoroughly  toasted  bread  in  thin  slices  and  crackers.  Soups  in 
general  and  milk,  unless  skimmed,  milk  puddings,  farinaceous  pud- 
dings, pastry,  salmon,  and  mackerel  are  all  to  be  avoided.  Fresh 
vegetables  and  fruits  are  allowed.  He  believes  it  is  useless  to  attempt 
to  give  rules  in  regard  to  the  actual  quantity  of  dry  food  permitted, 
because  it  must  necessarily  vary  in  accordance  with  the  weight  and 
strength  of  the  patient  in  each  case.  A  quantity  of  food  which  might 
constitute  an  excess  for  one  person  would  perhaps  be  insufficient  to 
support  the  strength  and  activity  of  another  of  larger  physique. 

Later  a  full  diet  of  meat  may  be  allowed,  but  sugars  and  starches 
are  still  excluded  to  as  great  an  extent  as  possible.  The  patient 
may  be  taught  to  supplement  passive  exercise  by  calisthenics. 

THE   DUJARDIN-BEAUMETZ    DIET 

Dujardin-Beaumetz  believes  that  the  diets  allowed  by  Oertel  and 
Ebstein  are  too  restricted  to  support  the  body  in  a  condition  of  nor- 
mal nutrition  and  activity,  and  his  system  of  treatment  is  as  follows : 
For  the  milder  cases  in  which  fatty  degeneration  has  not  yet  invaded 
the  heart  and  other  viscera  he  gives  half  a  pint  of  water  or  light  wine 
diluted  with  Vichy,  or  some  alkaline  effervescent  water,  with  each  of 
the  three  meals  of  the  day.  Soup  of  all  kinds  is  forbidden,  wine  or 
tea  being  recommended  instead.  If  the  gastric  juice  is  apparently 
deficient,  or  if  there  is  much  dyspepsia,  no  fluid  is  allowed  with  the 
meals,  but  the  patient  is  ordered  to  take  a  pint  of  weak  tea  without 
sugar  or  milk  two  hours  after  the  completion  of  each  meal.  No 
other  beverages  are  permitted  excepting  a  small  cup  of  black  coffee 
with  breakfast.  Soup  is  also  forbidden,  and  so  is  pastry.  He  allows 
dry  bread  in  moderation,  such  as  the  outer  part  of  Vienna  rolls,  or 
"  soup  sticks,"  which  are  chiefly  crust,  and  he  recommends  animal 
food  of  all  classes  and  several  varieties  of  fresh  vegetables  and  juicy 


OBESITY  705 

fruits,  such  as  oranges.  For  breakfast  he  gives  three  quarters  of  an 
ounce  of  dry  bread,  one  and  a  half  ounce  of  meat,  and  a  cup  of  weak 
tea  or  a  glass  or  two  of  light  wine.  Lunch  is  served  at  noon,  and 
consists  of  double  the  quantity  of  bread  and  meat  permitted  at  break- 
fast, with  three  ounces  of  fresh  vegetables,  salad,  a  small  piece  of 
cheese,  and  fruit.  Eggs  may  be  substituted  for  the  meat,  or  fish 
may  be  given  at  either  breakfast  or  luncheon.  The  quantity  of  the 
several  foods  allowed  may  be  varied  slightly. 

vox  NOORDEN'S  DIET 

Von  Noorden  recommends  the  following  dietary  for  ordinary  cases : 
At  8  o'clock  80  grams  (2l/2  ozs.)  of  lean  cold  meat,  25  grams  (nearly 
1  oz.)  of  bread,  one  cup  of  tea,  with  milk  and  no  sugar.  At  10  o'clock 
one  egg.  A  12  o'clock  one  cup  of  strong  broth.  At  1  o'clock  a  small 
plate  of  meat  soup,  150  grams  (5  ozs.)  of  lean  meat,  flesh  or  fish;  100 
grams  (3~y2  ozs.)  of  potatoes  with  salad;  100  grams  (3y2  ozs.)  of 
fresh  fruit.  At  3  o'clock  one  cup  of  black  coffee.  At  4  o'clock  200 
grams  (70  ozs.)  of  fresh  fruit.  At  6  o'clock  one-quarter  liter  of 
milk  with  tea.  At  8  o'clock  125  grams  (4  ozs.)  of  cold  meat  or  180 
grams  (6  ozs.)  of  meat,  raw  and  grilled,  and  eaten  with  radishes  and 
salads;  30  grams  (1  oz.)  of  Graham  bread,  and  two  to  three  tea- 
spoonfuls  of  cooked  fruit  with  sugar. 

THE    BOUCHARD    SYSTEM 

According  to  Bouchard's  method,  the  frequent  observation  of  the 
urine  should  form  the  basis  of  the  treatment  of  obesity.  When  the 
nitrogenous  waste  is  increased  in  the  urine  he  reduces  the  allowance 
of  animal  food;  but  he  also  believes,  in  opposition  to  many  other 
theories  of  treatment  of  obesity,  that  the  total  quantity  of  farina- 
ceous and  fatty  food  allowed  should  be  five  times  greater  than  the 
quantity  of  animal  food,  and  asserts  that  giving  vegetable  acids  with 
the  carbohydrates  favors  oxidation  of  the  latter.  He  therefore  pre- 
scribes such  fruits  and  fresh  vegetables  as  are  rich  in  the  potassium 
salts  of  the  organic  acids.  He  forbids  the  use  of  vinegar  and  other 
acids,  which  he  claims  diminish  the  alkalinity  of  the  blood  and  thereby 
increase  the  formation  of  fat. 

The  patient's  exercise  is  also  governed  by  the  elimination  of  urea 
and  phosphates.  When  these  salts  are  present  in  excess,  he  argues 
that  the  oxidation  of  the  tissues  is  being  unduly  stimulated;  but  if 
they  are  not  present  in  too  large  quantity,  exercise  before  meals  is 
recommended.  A  review  of  the  principles  involved  in  this  theory 
does  not  strengthen  the  belief  in  their  value. 
47 


706         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

The  oxidation  processes  in  the  body  are  still  too  obscure  to  en- 
able one  to  take  the  urine  as  an  absolute  criterion  of  the  conditions 
of  metabolism,  especially  in  those  cases  where  a  large  reduction  in 
the  body  weight  is  being  obtained  by  the  consumption  of  previously 
stored-up  material.  It  is  true  that  superfluous  fat,  when  fully  oxi- 
dized, leaves  the  body  in  the  form  of  carbonic  acid  and  water  from 
the  lungs,  and  in  the  form  of  water  and  carbonates  in  the  urine; 
but  it  is  not  definitely  known  to  what  extent  this  combustion  spares 
the  proteid  materials  of  the  body  from  disintegration  and  allows  the 
animal  food  products  to  pass  directly  into  the  urine  as  urea  or  other 
nitrogenous  waste  matter.  While  the  urine  should  carefully  be  stud- 
ied in  these  cases,  a  much  better  guide  for  the  treatment  of  obesity 
is  found  in  the  observation  of  other  symptoms  and  in  the  disappear- 
ance of  previously  existing  abnormal  conditions. 

THE    CHAMBERS    SYSTEM 

"  Day's  Regimen  for  a  Three  Weeks'  Course. —  Eise  at  7.  Rub  the 
body  well  with  horsehair  gloves,  have  a  cold  bath,  take  a  short  turn 
in  the  open  air.  Breakfast  at  8  or  8.30,  on  the  lean  of  beef  or  mut- 
ton, cutting  off  the  fat  and  skin,  with  dry  toast,  biscuit,  or  oatcake, 
a  tumbler  of  claret  and  water  or  tea  without  milk  or  sugar,  or  made 
in  the  Russian  way  with  a  slice  of  lemon.  Luncheon  at  1  on  bread 
or  biscuit,  Dutch  cheese,  salad,  water  cresses,  or  roasted  apples  (with- 
out sugar  or  cream),  hung  beef,  or  anchovies,  or  red  herring  or  olives, 
and  such  like  relishes.  Drink,  after  eating,  claret  and  water,  un- 
sweetened lemonade,  or  plain  water,  in  moderation.  Dinner  at  any 
convenient  hour.  Take  no  soup,  fish,  or  pastry,  but  plain  meat  of 
any  kind  except  pork,  rejecting  the  fat  and  skin.  Spinach,  French 
beans,  or  any  other  green  vegetable  may  be  taken,  but  no  potatoes, 
made  dishes,  or  pastry.  A  jelly  or  a  lemon  water  ice,  or  a  roast  apple 
must  suffice  for  sweets  and  dessert.  Claret  and  water  at  dinner,  and 
one  glass  of  sherry  or  Madeira  afterwards. 

"  Between  meals  exercise,  as  a  rule,  in  the  open  air,  to  the  extent 
of  inducing  perspiration,  must  be  taken.  Running,  when  practicable, 
is  the  best  form  in  which  to  take  it." 

Chambers  also  advised  giving  liquor  potassae  with  the  proteid  diet, 
or  the  remedy  of  Dancel,  consisting  of  one-half  or  a  teaspoonful  of 
sodium  bicarbonate  added  to  five  or  ten  grains  of  tartaric  acid  in  a 
small  tumblerful  of  water,  and  drunk  while  effervescing.  He  re- 
stricted sleep  to  seven  hours  a  day,  for  it  is  weakening  for  the  obese 
to  remain  too  long  in  bed  in  a  close  room.  Turkish  baths  were  also 
recommended.  Chambers's  further  directions  to  be  observed  by  the 


OBESITY  707 

patient  to  prevent  a  possible  return  to  corpulency  were  as  follows: 
Continue  to  avoid  fat  meats,  rich  milk,  butter,  malt  liquors,  sweet 
wines,  starches,  especially  pastry  and  puddings,  and  sweet  vegetables, 
such  as  parsnips  and  beets.  The  patient  may  have  lean  beef  or  mut- 
ton, venison,  game,  poultry,  boiled  fish,  poor  new  cheese,  green  vege- 
tables and  fresh  fruits,  oranges,  lemons,  almonds,  roast  apples,  salads, 
olives,  buttermilk,  claret,  hock.  Bread  should  be  aerated  or  toasted. 
Sea  biscuits  may  be  eaten.  Among  the  green  vegetables  which  may 
be  eaten  are  tomatoes,  celery,  stuffed  red  and  green  peppers,  radishes, 
asparagus,  artichokes,  oyster  plant,  squash,  and  spinach. 

THE   DEBOVE   SYSTEM 

Debove's  theory  of  obesity  is  that  the  nervous  system  is  at  fault 
through  failure  to  regulate  metabolism.  His  treatment  comprises 
(1)  a  period  of  reduced  feeding,  (2)  a  period  of  voluntary  regu- 
lation. His  sample  diet  is  as  follows: 

For  breakfast,  a  cup  of  tea  or  milk;  mid-day  meal,  one  or  two 
slices  of  meat,  a  few  vegetables  or  a  little  salad,  a  hundred  to  a 
hundred  and  fifty  grams  of  bread,  a  little  cheese,  fruits  as  desired, 
and  a  cup  of  black  coffee  without  sugar.  For  supper,  a  glass  of 
hot  milk,  sweetened,  30  to  50  grams  of  bread,  and  fruits  as  desired. 

Summary  of  Dietetic  Treatment. 

The  above  systems,  comprising  the  theories  of  distinguished  Ameri- 
can, English,  German  and  French  dieticians,  are  of  interest  in  con- 
firmation of  the  oft-quoted  adage,  "  One  man's  meat  is  another  man's 
poison,"  and  confirm  the  fact  that  obesity  is  a  complex  condition 
arising  from  varied  causes,  and  therefore  amenable  to  varied  treat- 
ment. 

Of  the  various  systems  above  described,  that  of  Oertel  is,  on  the 
whole,  the  best  adapted  for  the  greater  number  of  cases.  The  Eb- 
stein  treatment  diminishes  the  appetite  and  is  useful  for  robust 
patients,  but  if  there  is  enfeebled  digestion  and  weakness,  this  diet 
is  not  to  be  recommended  on  account  of  the  large  proportion  of  fat 
and  the  relatively  small  amount  of  proteid  foods.  The  essential  value 
of  all  methods  of  dietetic  treatment  of  obesity  is  based  upon  two 
objects  to  be  attained:  First,  to  enable  the  patient  to  oxidize  fully 
and  eliminate  the  fat  which  is  already  accumulated  in  various  parts  of 
the  body,  and,  secondly,  to  make  it  impossible  for  it  to  be  reformed. 

From  what  has  been  said  of  the  cause  and  nature  of  obesity,  it 
follows  that  no  one  system  of  treatment  is  applicable  in  every  in- 
stance. The  effect  of  any  treatment  should  be  observed  from  day 


708          DISEASES   ESPECIALLY   INFLUENCED   BY   DIET 

to  day,  care  being  taken  that  the  patient  while  losing  flesh  does  not 
at  the  same  time  lose  in  strength  to  a  degree  which  may  become 
dangerious  —  i.  e.,  more  than  two  or  three  pounds  per  week.  Under 
any  "  system "  frequent  examinations  should  be  made  of  the  heart 
action,  the  circulation,  and  the  urine. 

The  aged  seldom  become  obese,  or  rather  the  very  obese  seldom  be- 
come aged,  but  when  they  do,  reduction  treatment  is  ill  borne  and 
liable  to  induce  fatal  weakness.  In  many  cases,  especially  among 
children  and  youth  and  in  all  patients  having  weak  hearts,  it  is  better 
to  prescribe  a  reduction  treatment  of  limited  duration  —  six  weeks 
or  two  months  —  and  alternate  it  with  longer  t  intervals  of  less  re- 
stricted diet.  In  this  manner  strength  is  better  maintained  and  de- 
velopment is  not  checked.  Moderate  increase  in  body  fat  in  the 
middle-aged,  does  not  necessitate  reduction  treatment  (except  on 
esthetic  grounds),  but  it  should  be  kept  from  advancing.  As  a  rule, 
rapid  reduction  cures  produce  less  lasting  effects  than  slower  treat- 
ment. 

Dangers  of  Reduction  Cures. —  At  the  extremes  of  age,  and  in 
enormously  fat  subjects,  reduction  when  it  has  caused  a  loss  of  20  or 
30  pounds  or  more  sometimes  causes  evil  effects,  such  as  cardiac  weak- 
ness, hernias,  gastroptosis  or  nephrotosis,  owing  to  a  pendulous,  flabby 
abdomen,  or  gallstone  colic  from  the  same  cause.  Cases  complicating 
gout  are  described  on  page  717. 

Following  is  a  list  of  foods  which  may  be  eaten  by  those  who  wish 
to  prevent  growing  stouter  or  regaining  weight  which  has  been  lost 
under  a  more  strict  reduction  diet. 

PREVENTIVE  DIETARY  FOR  OBESITY 

FOODS  ALLOWED. — 

Shellfish  and  Crustaceans:     Oysters,  clams,  scallops,  lobster. 

Eggs  in  any  form,  but  not  more  than  two  a  day. 

Meats:  Lean,  red  meats;  beefsteak,  chops,  lamb,  mutton,  veal, 
chicken,  capon,  turkey  (without  "stuffing"  or  sauces),  sweetbread, 
lean  ham,  corned  beef,  smoked  beef.  All  meats  to  be  eaten  sparingly 
and  not  oftener  than  once  a  day. 

Fish:  Fresh  fish  of  any  kind  except  salmon,  mackerel,  bluefish 
(as  being  too  rich  in  fat). 

Vegetables:  String  beans,  lettuce,  spinach,  cress,  celery,  Brussels 
sprouts,  cauliflower,  cabbage,  onions,  okra,  carrots,  turnips,  parsnips, 
squash,  tomatoes,  cucumbers,  artichokes,  leeks,  radishes,  cranberries, 
oyster  plant. 

Fruits:     Oranges,  lemons,  pears,  apricots,  peaches,  cherries,  berries 


OBESITY  709 

(without  sugar  and  cream),  plums,  pineapples,  apples  in  any  form. 

Mushrooms. 

Pickles,  spices,  condiments,  vinegar. 

Stale  bread  and  dry  toast  with  two  meals  only,  and  in  moderate 
quantity. 

Butter,  not  more  than  one-fourth  ounce  a  day. 

Saccharin  in  lieu  of  sugar. 

Tea,  coffee,  with  cream  and  sugar. 

SPECIAL  EULES. — 

Desserts:     Unsweetened  gelatin  foods,  cooked  fruits. 

1.  Do  not  drink  water  within  an  hour  before  or  two  hours  after 
meals. 

2.  Eat  slowly;  masticate  thoroughly. 

3.  Do  not  have  more  than  three  courses  or  five  kinds  of  food  at 
any  one  meal. 

4.  Eat  moderately,  not  to  satiety. 

FOODS  FORBIDDEN. —  Soups,  broths,  purees. 

Cereals  and  breadstuffs  of  all  kinds,  except  a  little  white  bread  or 
toast.  Gingerbread,  crackers,  brown  bread,  corn  bread,  rice,  hominy, 
oatmeal,  wheaten  grits,  shredded  wheat,  crackers,  macaroni,  spaghetti, 
farina,  sago,  cornstarch,  tapioca,  muffins. 

Fats  and  oils,  olive  oil,  cream,  fat  bacon,  lard. 

Desserts:  Preserves,  puddings,  pies,  pastry,  cake,  cakes,  sugar, 
sirup,  candy  and  confectionery,  fancy  desserts  of  all  kinds,  nuts, 
raisins,  jams,  marmalade. 

Game,  goose,  duck,  pork,  sausage,  patties. 

Vegetables:  White  and  sweet  potatoes,  peas,  beans,  corn,  Lima 
beans,  eggplant,  beets. 

Miscellaneous:  Liver,  kidneys,  marrow,  tongue,  cheese,  terrapin, 
chowder,  milk,  chocolate,  cocoa,  effervescing  waters,  lemonade,  orange- 
ade. 

All  food  should  be  cooked  simply,  and  twice-cooked  or  "  made  over  " 
dishes  should  be  avoided,  as  well  as  all  fried  foods. 

Do  not  add  in  cooking  foods  which  should  be  withheld,  such  as 
butter,  flour,  cream,  milk  and  eggs. 

The  thyroid-gland  extract  has  a  remarkable  effect  in  reducing 
obesity  in  some  cases,  even  without  accessory  treatment.  The  ka- 
tabolism  of  the  process  is  not  understood,  but  the  C02  elimination  is 
increased,  and  in  addition  to  increased  consumption  of  fat  tissues 
there  is  increased  nitrogenous  waste.  The  effect  is  not  permanent, 
and  the  lost  weight  is  soon  regained  if  the  patient  fails  to  persist  in 
dietetic  treatment  with  exercise.  The  powdered  gland  is  given  in 


710        DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

tablet  form,  in  doses  not  exceeding  five  grains  three  times  a  day. 
It  is  best  not  to  give  more  than  one  or  two  grains  at  first  in  twenty- 
four  hours,  for  the  remedy  sometimes  produces  serious  cardiac  weakness 
and  digestive  disturbance.  I  have  usually  found  that  after  a  reduc- 
tion in  weight  of  about  thirty  pounds  the  extract  had  to  be  discon- 
tinued. C.  P.  Beebe  has  derived  a  modified  extract. 

"  Anti-Fat "  Remedies 

A  host  of  quack  nostrums  are  offered  to  a  credulous  public  un- 
der the  claim  that  they  reduce  corpulency.  Some  of  them  have 
achieved  reputation  because  while  they  are  taken  the  patient  is  also 
induced  to  regulate  his  diet ;  others  merely  because  they  have  destroyed 
the  appetite  or  digestion  and  have  made  it  impossible  to  eat  too  much 
food.  But  the  whole  lot  of  "  reduction  pills,"  concentrated  salts  and 
purges,  extracts  of  phytolacca  berries,  Fucus  vesiculosus,  and  other 
so-called  "  specifics  "  for  reduction  of  obesity,  cannot  be  condemned 
too  strongly  as  thoroughly  unscientific,  if  not  positively  harmful  or 
dangerous,  as  many  of  them  are. 

It  cannot  be  expected  that  any  chemical  remedy  can  control  the 
complex  physiological  and  metabolic  processes  involved,  and  the  sub- 
stances which  are  in  extensive  use  by  credulous  persons  for  this  pur- 
pose diminish  the  appetite,  impair  the  digestion,  and  seriously 
interfere  with  nutrition.  In  such  manner  only  do  they  reduce 
corpulency. 

Excepting  the  thyroid  extract  there  is  no  drug  or  remedy  known 
which  acts  specifically  either  in  retarding  fat  formation  or  in  causing 
its  destruction  in  the  body,  and  when  any  such  remedy  appears  to 
have  that  effect,  it  is  acting  indirectly  by  a  general  lowering  of 
vitality. 

Diet  for  Leanness 

The  foods  which  tend  to  produce  fat  in  the  body  are  chiefly  sugars 
and  starches.  Eating  fat  in  excess  does  not  necessarily  cause  fat  to 
accumulate  in  the  system,  for  it  may  be  oxidized  completely,  but  it 
may  be  a  contributing  factor. 

To  increase  the  albuminous  constituents  of  the  body  without  the 
addition  of  fat,  a  diet  should  be  ordered  in  which  proteid  food  pre- 
dominates, with  a  moderate  allowance  of  carbohydrates.  To  increase 
the  body  fat,  however,  the  proportion  of  carbohydrate  should  con- 
siderably exceed  the  proteid  food  and  a  little  fat  should  be  added. 

Fn  seeking  to  remedy  excessive  leanness  by  dietetic  treatment  it 
is  obviously  necessary  first  to  ascertain,  if  possible,  its  cause.  It 


OBESITY  711 

may  be  due  to  the  use  of  improper  food,  to  erroneous  habits  of  eating, 
bad  cooking,  mal-digestion  or  mal-assimilation,  overwork  and  nervous 
exhaustion,  disease  of  the  various  organs  connected  especially  with 
nutrition,  and  besides  these  and  other  causes  there  are  those  cases 
in  which  leanness  seems  to  be  constitutional  or  hereditary.  Patients 
of  the  latter  type  may  enjoy  excellent  health,  but  are  always  so  thin  as 
to  be  the  subject  of  comment.  No  diet  seems  to  have  much  effect  in 
increasing  their  weight.  Another  class  of  persons  are  those  whose 
weight  is  constantly  fluctuating  and  whose  annual  variation  is  as 
much  as  ten  or  twenty  pounds.  In  winter,  in  town  life,  when 
overworked,  worried,  or  oppressed  with  mental  strain,  they  lose  weight 
rapidly,  and  in  summer,  during  a  holiday  in  the  country,  with  little 
to  do  but  eat,  sleep  and  live  an  outdoor  life,  they  gain  at  the  rate 
of  two  or  three  pounds  a  week.  This  is  true  more  often  of  those 
whose  general  tendency  is  towards  obesity  rather  than  towards  lean- 
ness. 

Leanness  is  a  decided  advantage  in  heart  disease,  gout,  and  chronic 
rheumatism,  because  less  effort  is  required  by  a  light-weight  body 
in  locomotion,  but  in  tuberculosis,  neurasthenia  and  diabetes  it  is 
distinctly  a  poor  symptom  to  be  lean. 

It  is  almost  hopeless  to  attempt  to  remedy  obstinate  leanness  by 
diet  unless  other  favoring  conditions  can  be  secured.  First  among 
these  is  entire  freedom  from  mental  strain,  and  of  almost  equal  im- 
portance is  abundant  and  regular  sleep.  A  warm  climate  and  inac- 
tive life  favor  increase  in  weight.  In  most  respects  the  diet  for 
leanness  is  the  reverse  of  that  for  obesity,  as  would  naturally  be 
expected,  and  in  prescribing  starchy  foods  it  should  be  remembered 
that  the  leanness  often  is  caused  solely  by  an  entire  inability  to  digest 
amylaceous  or  saccharine  material  owing  to  "  nervous  dyspepsia," 
gastric  catarrh,  etc.  These  conditions  should  receive  treatment  on 
the  lines  recommended  on  pp.  583,  584.  By  a  little  care  it  will 
often  be  possible  to  discover  some  forms  of  starches  which  can  be 
digested.  It  is  a  good  rule  in  such  cases  to  prescribe  cereals  or  vege- 
tables at  one  meal  and  meat  at  another,  so  that  articles  involving 
different  rates  and  organs  of  digestion  do  not  interfere  with  each 
other.  (See  Digestion  in  the  Stomach,  p.  390,  and  Intestines,  p.  393.) 
All  bread  should  be  stale  or  toasted.  Crackers  and  zwieback  may  be 
allowed.  Usually  such  patients  may  be  made  to  digest  starches  be- 
fore they  can  sugars  —  oatmeal  will  be  better  digested  without  sugar, 
and  a  cup  of  sweetened  coffee  with  a  meal  of  starchy  foods  may  pro- 
duce flatulency  which  lasts  for  hours. 

It  is  desirable  to  increase  the  body  weight  (a)  after  serious  acute 


712          DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

disease,  (&)  in  chronic  wasting  disease  (especially  tuberculosis), 
(c)  in  conditions  of  nervous  exhaustion  (neurasthenia). 

When  the  digestive  organs  admit,  the  following  articles  may  be 
prescribed  in  the  diet  for  leanness : 

Abundant  fat  meats,  eggs,  bacon,  butter,  cream,  milk,  cocoa,  and 
chocolate.  White  and  sweet  potatoes,  baked  beans,  Lima  beans,  but- 
ter beans,  string  beans,  peas,  beets,  corn,  samp,  macaroni,  bread  and 
well-cooked  cereals,  especially  oatmeal,  hominy,  and  cornmeal, 
farinaceous  puddings  with  sugar  and  cream,  sago,  tapioca,  cake,  cus- 
tards, sweets,  sirup,  honey,  chocolate,  sweet  wines,  port,  porter,  stout, 
ales,  and  beer.  Malt  preparations  are  also  helpful.  Sweet  fruits  may 
be  eaten.  To  be  avoided  are  pickles,  acids,  condiments,  much  bulk  of 
green  vegetables  or  lean  meat  and  strong  liquors. 

Muscular  as  well  as  mental  rest  should  be  enjoined  if  any  dietetic 
treatment  for  leanness  is  to  be  successful.  It  is  by  no  means  always 
necessary  or  possible  to  keep  the  patient  in  bed,  but  disproportionate 
exercise  (especially  long,  fatiguing  walks),  offsets  the  benefits  of  diet. 
Excessive  leanness  may  not  be  incompatible  with  the  enjoyment  of 
perfect  health,  and,  upon  the  whole,  it  is  less  uncomfortable  than 
excessive  stoutness;  yet  in  the  very  lean,  bodily  resistance  against 
certain  forms  of  disease,  especially  chronic  ailments,  is  diminished, 
the  subject  of  leanness  is  prone  to  suffer  from  cold  and  often  from 
digestive  disorders,  muscular  fatigue  may  be  easily  induced,  and  in 
youths  who  have  grown  rapidly  to  extreme  height,  disproportionate 
leanness  leads  to  stunted  development  in  other  directions,  especially 
that  of  normal  chest  expansion.  Other  persons,  especially  young 
women,  complain  of  their  leanness  upon  aesthetic  grounds. 

The  important  principle  to  impress  upon  the  subject  of  leanness 
is  that  he  should  learn  to  make  a  storage  battery  of  himself ;  i.  e.,  if  he 
expend  his  energies  too  fast  in  any  direction,  the  food  which  is  their 
ultimate  source  will  never  be  stored  as  a  source  of  latent  energy.  The 
difficulty  may  be  hereditary,  constitutional,  or  acquired,  but  it  only 
may  be  overcome  by  appreciating  the  full  significance  of  this  prin- 
ciple. 

ACUTE  RHEUMATISM 

Causation. —  It  has  not  been  proved  that  any  special  articles  of 
diet  lead  to  the  development  of  rheumatism,  although  indulgence  in 
sweets,  starchy  foods,  and  malt  liquors  is  sometimes  held  responsible 
for  it.  The  prevailing  opinion  is  that  acute  rheumatism  is  an  infec- 
tions disease,  hence  there  is  no  reason  that  diet  should  exercise  any 


ACUTE   RHEUMATISM  713 

primary  etiological  influence  in  producing  rheumatism  or  in  prevent- 
ing recurrent  attacks,  beyond  the  obvious  fact  that  a  diet  which  dis- 
orders digestion  or  gives  rise  to  malnutrition  places  the  system  in  a 
condition  more  susceptible  to  the  inroads  of  any  microbic  disease  — 
in  other  words,  it  lowers  resistance.  This  statement,  however,  by  no 
means  precludes  the  fact  that  during  an  acute  attack  diet  may  exert 
profound  influence  as  it  does  in  many  other  febrile  diseases  which  it 
does  not  originate. 

Dietetic  Treatment. —  While  the  fever  lasts  and  other  symptoms 
are  acute,  such  as  pain  and  swelling  of  the  joints,  the  patient  should 
be  put  upon  a  fluid  diet.  The  majority  of  patients  do  best  at  this 
time  with  an  exclusive  milk  or  bread-and-milk  diet.  Those  patients 
who  cannot  take  milk,  however,  may  be  allowed  soups  and  broths  fla- 
vored with  vegetable  extracts,  chicken  soup,  milk  toast,  barley  or  oat- 
meal gruel,  caudle,  clam  broth. 

Thirst  is  often  a  prominent  symptom,  especially  if  there  be  much 
fever,  and  it  is  advisable  for  the  patient  to  drink  fluid  freely  to  assist 
in  washing  out  the  waste  products  from  the  body.  Lemonade  and 
slightly  acid  drinks  of  various  kinds,  such  as  dilute  phosphoric  acid 
or  the  effervescent  mineral  waters,  are  recommended.  Boiled  milk 
with  soda,  Seltzer  or  Vichy  may  be  drunk,  or  oatmeal  or  barley  water 
flavored  with  lemon.  Alcohol  should  be  avoided  while  the  acute 
symptoms  last,  unless  the  complication  of  inflammation  of  the  endo- 
cardium or  pericardium  enfeeble  the  heart  action  to  such  degree  as 
to  make  stimulation  necessary.  If  convalescence  be  prolonged  and 
anaemia  considerable,  alcohol  may  be  prescribed  as  a  tonic  two  or 
three  times  a  day  in  the  form  of  a  glass  of  claret  or  Burgundy  (one 
to  two  ounces),  or  diluted  whisky. 

During  convalescence  the  appetite  is  not  usually  vigorous,  and  it 
is  not  necessary  to  urge  the  taking  of  much  food  at  first.  The  diet 
should  be  principally  farinaceous,  but  not  saccharine. 

Such  articles  may  be  given  as  rice  (plain  or  spiced),  arrowroot, 
oatmeal,  hominy,  cornmeal,  semolina,  wheaten  grits,  panada,  milk 
toast,  simple  unsweetened  puddings,  wine  jelly,  blancmange,  and 
malted  foods. 

The  return  to  solid  diet  should  be  gradual,  and  for  a  long  time 
the  patient  should  abstain  from  eating  meats  as  well  as  from  pastry 
and  sweets.  The  late  Sir  Hilton  Fagge  stated  that  no  meat  or  fish 
should  be  allowed  for  at  least  a  week  after  subsidence  of  the  fever 
and  acute  symptoms,  or,  better,  for  a  fortnight,  and  many  believe  that 
beef  tea  is  harmful.  Meat  undoubtedly  may  induce  a  relapse. 

"When  convalescence  becomes  established,  eggs,  sweetbread,  fish, 
48 


714          DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

oysters,  and  the  white  meat  of  broiled  or  roasted  chicken  may  be  given, 
and  one  or  two  such  vegetables  as  asparagus,  spinach,  or  stewed  celery, 
with  a  baked  apple  or  fresh  fruit,  but  sweets  and  alcohol  should  long 
be  withheld. 

The  patient  should  be  fed  often,  having  one  or  two  extra  lunches 
during  the  day,  for  anaemia  is  apt  to  prevail  for  some  time,  and 
abundant  nutriment  is  required. 

I  am  often  asked  for  preventive  diet  for  rheumatism,  especially 
for  children  who  have  had  one  or  more  acute  attacks,  but  I  know  of 
none  beyond  general  directions  to  eat  simply  cooked,  plain  food,  avoid- 
ing excess  of  red  meat  and  sweets,  and  taking  fresh  fruit  for  laxative 
effect. 

CHRONIC  RHEUMATISM 

.  In  the  dietetic  treatment  of  chronic  rheumatism,  especially  if  the 
patient  is  anaemic,  animal  food  should  not  be  excluded,  but  the  basis 
of  the  diet  should  be  farinaceous  food,  with  fresh  green  vegetables  and 
fruits.  Fish,  eggs,  and  fowl  may  be  eaten,  but  much  red  meat  is  not 
desirable.  Sweets  and  alcoholic  beverages  should  be  omitted  from  the 
menu,  and  all  foods  should  be  plainly  cooked  and  eaten  in  moderation. 

ARTHRITIS  DEFORMANS 

Causation. —  Arthritis  deformans  is  a  chronic  disease  in  which  the 
joints  of  the  body,  and  particularly  those  of  the  extremities,  are 
affected.  The  alterations  in  joint  structures  are  produced  mainly 
by  impoverished  nutrition,  and  the  disease  is  often,  but  not  always, 
one  of  advanced  life,  occurring  in  persons  in  whom  various  evidences 
of  senility  have  begun  to  appear.  The  structural  changes  in  the 
joints  involve  proliferation  of  the  cellular  elements  of  the  cartilages, 
with  thickening  and  erosion  and  with  the  production  of  osteophytes. 
In  mild  cases  there  is  not  much  impairment  of  general  health.  In 
severer  cases  the  patient  is  confined  to  the  house  and,  on  account  of 
pain  or  immobility  of  the  joints,  is  unable  to  take  ordinary  exercise. 
Digestion  and  nutrition  suffer  considerably  in  consequence. 

Dietetic  Treatment. —  Whereas  the  disease  is  one  of  debility  and  im- 
poverished nutrition,  it  follows  that  in  it,  unlike  acute  rheumatism,  a 
low  diet  is  harmful  and  a  nourishing  diet,  with  increased  frequency 
of  meals,  is  desirable.  The  late  James  Stewart  of  Montreal,  wrote: 
"The  practice  of  limiting  the  amount  of  proteid  food  is  not  to  be 
commended.  Provided  there  is  no  general  or  local  contraindication, 


AETHRITIS  DEFORMANS  —  GOUT  715 

the  patient  should  be  directed  to  take  as  much  nitrogenous  food  as 
can  be  digested  with  facility."  And  Garrod  wrote :  "  I  consider  it 
of  the  utmost  importance  throughout  the  whole  course  of  the  disease 
to  support  the  system  and  to  allow  the  patient  as  nourishing  a  diet 
as  he  is  capable  of  properly  digesting."  Good  roast  beef,  beefsteak, 
mutton,  fowl,  fish,  eggs,  and  milk  may  be  eaten,  with  fresh  vegetables, 
fruits  and  cereals. 

The  objection  which  exists  to  the  use  of  alcohol  in  gout  and  acute 
rheumatism  does  not  apply  with  such  force  in  this  disease.  Malt 
liquors  may  be  given,  such  as  ale  or  stout,  and  it  is  often  desirable 
to  prescribe  a  good  Burgundy,  port,  or  sherry.  If  it  is  well  borne  by 
the  stomach,  cod-liver  oil  should  be  given  in  tablespoonful  doses,  an 
hour  after  meals,  three  times  a  day.  It  is  an  excellent  food  in  thia 
disease,  and  its  use  should  be  long  continued.  Other  forms  of  fat 
may  be  used,  such  as  butter,  cream,  or  bone  marrow,  olive  oil,  fat 
bacon,  etc. 

When  acute  exacerbations  arise  the  quantity  of  food  and  stimu- 
lants should  be  reduced,  but  otherwise  it  is  important  that  the  diet 
always  should  be  ample,  and  in  debilitated  patients  the  "  forced 
feeding"  detailed  on  page  515  may  prove  beneficial.  Practically  the 
only  restrictions  in  quality  of  food  are  to  omit  sweets,  desserts  and 
"  fancy  "  dishes,  which  satisfy  the  appetite  without  leaving  room  for 
more  wholesome  food. 

Patients  do  well  to  try  the  effect  of  a  course  of  treatment  at  the 
"Hot  Springs"  of  Virginia,  Arkansas,  Mount  Clemens  (Michigan), 
French  Lick  (Indiana),  Banff  (Canada),  Aix  les  Bains  (France), 
Wiesbaden  (Germany),  or  Marienbad  (Bohemia). 

GOUT 

Gout  is  a  constitutional  disease  which  has  local  manifestations 
appearing  from  time  to  time  in  the  joints,  especially  the  metacarpo- 
phalangeal  articulation  of  the  great  toe,  the  finger,  knee,  and  other 
joints,  but  the  gouty  diathesis  is  a  condition  which  once  acquired  may 
exist  for  years,  producing  many  other  and  more  serious  symptoms  or 
structural  changes  in  the  body  than  the  local  inflammation  of  one  or 
more  joints. 

Causation. —  Gout  has  been  defined  as  "a  condition  dependent 
upon  disturbed  retrograde  metamorphosis  of  the  nitrogenous  in- 
gredients of  the  food"  —a  high-sounding  phrase,  which,  must  be 
confessed,  carries  with  it  very  little  genuine  explanation  of  the  nu- 
tritive processes  involved.  Whatever  may  be  the  theories  in  regard 


716         DISEASES   ESPECIALLY   INFLUENCED   BY   DIET 

to  the  production  of  an  attack  of  acute  gout,  it  is  universally  ad- 
mitted that  careful  regulation  of  the  diet  is  a  most  important  factor 
in  its  treatment.  Gout  and  the  various  conditions  allied  to  it  are 
dependent  upon  retention  in  the  blood  or  other  fluids  of  the  body  of 
forms  of  waste  matter  which  normally  should  be  oxidized  and  com- 
pletely converted  into  the  soluble  materials  which  are  excreted  in 
the  urine.  For  some  reason  the  oxidation  of  waste  matter  is  sus- 
pended, and,  as  a  result,  a  variety  of  intermediate  products  of  im- 
perfect solubility  may  be  deposited  in  the  joints  or  tissues  of  the  body. 
The  active  manifestations  of  gout  are  due  to  an  accumulation  of  in~ 
soluble  sodium  biurate  in  the  joints.  In  a  condition  closely  allied 
to  gout,  the  uric-acid  diathesis,  there  may  be  a  deposition  of  crystals 
of  uric  acid  in  some  portion  of  the  urinary  tract. 

The  direct  relation  existing  between  uric  acid  and  gout  has  been 
exhaustively  investigated  by  Garrod,  and  this  relation  may  be  briefly 
summarized  as  follows:  First,  the  gouty  diathesis  is  associated  with 
a  more  or  less  constant  excess  of  uric  acid  in  the  blood;  secondly,  the 
quantity  of  uric  acid  normally  present  in  the  urine  is  diminished  by 
at  least  one-half  during  a  severe  attack  of  gout,  and  increases  beyond 
the  normal  as  soon  as  the  acute  symptoms  subside.  An  acute  attack 
of  gout  is  therefore  preceded  by  accumulation  of  uric  acid  in  the 
blood,  a  substance  that  in  itself  represents  incomplete  proteid  katab- 
olism  in  the  body.  The  retention  of  this  fo,rm  of  waste  in  con- 
siderable quantity  proves  markedly  irritating  to  mucous  and  serous 
membranes,  as  well  as  to  the  nervous  and  other  organs  of  the  body. 

Sir  Dyce  Duckworth  writes:  "We  perhaps  come  nearer  a  com- 
plete understanding  of  this  matter  if  we  regard  as  present  in  the 
gouty  a  peculiar  incapacity  for  normal  elaboration  within  the  whole 
body,  not  merely  in  the  liver  or  in  one  or  two  organs,  of  food, 
whereby  uric  acid  is  formed  at  times  in  excess,  or  is  incapable  of 
being  duly  transformed  into  more  soluble  and  less  noxious  products," 
and  he  agrees  with  Ralfe  that  the  failure  to  complete  the  metabolism 
of  uric  acid  is  dependent  primarily  upon  disturbed  innervation. 

In  referring  to  the  habit  of  overeating  Sir  Henry  Thompson  says 
that  in  early  life  it  may  cause  occasional  attacks  of  biliousness,  but 
after  the  first  half  of  life  has  been  spent  the  remaining  half  may  be 
affected  in  a  different  way,  and  "recurring  attacks  of  gout  perform 
the  same  duty,  or  nearly  so,  at  this  period  of  life  that  bilious  attacks 
accomplished  in  youth."  On  the  other  hand,  in  persons  who  are 
subject  to  attacks  of  gout,  starvation  may  bring  it  on  (Senator),  and 
"  poor  man's  gout "  is  by  no  means  a  disease  induced  by  plenty. 

Sugar  oaten  in  excess  is  not  of  itself  a  direct  cause  of  gout,  but 


GOUT  717 

sweets  combined  with  certain  other  foods,  such  as  special  sweet  fruits 
and  wines,  will  precipitate  an  attack  in  a  gouty  subject  with  certainty. 
It  is  the  combination  of  sugar  with  vegetable  acids  which  is  injurious. 

Sugar,  under  some  conditions  of  fermentation  in  the  stomach 
and  intestines,  forms  lactic  acid,  which  is  capable  of  splitting  so  as  to 
produce  carbon  dioxide,  which,  according  to  Ealfe,  forms  acid  salts 
of  sodium  and  potassium  from  their  neutral  compounds. 

Among  the  laboring  classes  in  my  wards  in  Bellevue  and  the  Pres- 
byterian Hospital  are  many  cases  of  acute  Sydenham's  gout.  Such 
cases  are  sometimes  met  with  among  cooks  who  have  tasted  much  rich 
food,  sometimes  among  ill-fed  men  who  have  lived  upon  poor,  coarse 
food  and  drunk  a  poor  grade  of  malt  liquors  and  spirits. 

Lack  of  exercise  is  often  assigned  as  a  cause  for  gout,  and  with 
many  persons  it  is  true  that  outbreaks  may  be  intensified  in  this  way ; 
but  it  is  not  uncommon  for  the  disease  to  affect  men  who  lead  lives 
of  considerable  activity  or  who  practice  athletics,  but  who  at  the  same 
time  consume  large  quantities  of  proteid  and  sweets.  In  the  latter 
class,  by  free  perspiration  the  amount  of  fluid  present  in  the  blood  is 
reduced  and  the  solids  become  both  relatively  and  absolutely  increased, 
making  it  difficult  or  impossible  for  them  all  to  become  thoroughly 
oxidized. 

Symptoms. —  The  distinctive  symptoms  of  gout  are  the  local  joint 
peripheral  manifestations  of  pain,  swelling,  redness,  and  tenderness. 
These  symptoms  usually  occur  together  in  an  acute  attack,  but  either 
one  occasionally  may  be  absent.  Other  symptoms  may  appear  from 
time  to  time,  such  as  catarrhs  of  the  mucous  membranes,  especially 
of  the  stomach,  bowels,  and  respiratory  passages ;  arterio-sclerosis ;  al- 
terations in  the  composition  of  the  urine;  and  various  forms  of  irri- 
tation of  the  nervous  system  and  the  skin. 

Children  who  inherit  the  gouty  diathesis  are  very  liable  to  present 
some  one  or  more  of  this  group  of  symptoms,  especially  neuralgic 
pains,  digestive  disturbances,  and  skin  diseases,  which  appear  at  an 
early  age  and  long  before  the  gout  is  fully  developed  with  typical 
localized  joint  symptoms.  The  symptoms  connected  with  this  diath- 
esis are  believed  to  arise  from  obscure  alterations  in  the  composi- 
tion of  the  blood  which  are  more  or  less  remediable  by  dietetic  treat- 
ment. 

Preventive  Treatment. —  The  prophylactic  treatment  of  gout  in 
those  who  inherit  a  constitutional  predisposition  to  the  disease  is 
very  important.  From  birth  onward  the  children  of  gouty  parents 
should  be  abstemious  and  have  the  diet  balanced  so  that  neither 
animal  nor  vegetable  food  predominates  in  great  excess.  As  the 


718         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

child  grows  older,  confectionery  and  sweets  in  general  should  be 
avoided,  especially  with  other  food  or  at  the  conclusion  of  meals,  as 
well  as  alcohol  in  every  form.  In  youth  all  varieties  of  beer,  ale,  etc., 
are  particularly  injurious. 

Among  adults  tea  and  coffee,  if  allowed  at  all,  should  be  taken  in 
moderation,  and  some  persons  may  precipitate  a  violent  attack 
of  gout  by  a  single  glass  of  champagne  or  sweet  wine.  If  they  are 
accustomed  to  the  use  of  alcoholic  beverages  and  it  is  impossible  to 
do  without  them,  those  which  are  least  injurious  are  a  dry  white  wine 
or  old  Bordeaux,  but  all  wines  containing  sugar  are  absolutely  pro- 
hibited. 

Cyr  says :  "  If  a  glass  of  beer,,  spirits,  or  wine  is  habitually  fol- 
lowed by  pain  in  a  joint  or  nerve  it  is  gouty." 

Theory  of  Dietetic  Treatment. —  An  important  question  in  regard 
to  the  theory  of  gout  is  still  under  discussion  —  namely,  whether  the 
increased  quantity  of  uric  acid  is  to  be  attributed  to  overproduction 
or  merely  to  faulty  elimination.     It  is  conceivable  that  the  fluids 
of  the  body,  by  becoming  less  alkaline  than  normal,  may  fail  to  re- 
tain the  salts  of  uric  acid  in  solution,  which  are  consequently  precipi- 
tated in  the  joints  and  elsewhere.     The  matter  is  of  vital  importance 
in  the  selection  of  the  proper  diet  for  gouty  patients.     If  the  disease 
were  caused  merely  by  imperfect  oxidation  of  proteids,  the  indication 
would  be  to  lessen  the  quantity  of  such  food  ingested  and  to  promote 
oxidation  by  exercise  and  fresh  air.     If,  on  the  other  hand,  oxidation 
processes  are  fairly  normal,  but  the  blood  is  in  a  morbid  state  in  which 
it  becomes  less  alkaline  than  normal  and  loses  its  solvent  power  upon 
the  proteid  waste,  it  is  possible  that  other  causes  may  be  responsible 
for  the  condition  produced.     Proteids  contain  both  sulphur  and  phos- 
phorus which  are  destined  to  leave  the  body  in  the  form  of  salts  of 
sulphuric  and  phosphoric  acids  respectively.     If  these  acids  fail  to 
be  neutralized  wholly  while  yet  in  the  blood  they  will  lessen  its 
alkalinity,  and  in  this  way  overindulgence  in  proteid  food  by  furnish- 
ing an  excess  of  sulphur  and  phosphorus  may  produce  uricaemia. 
This  theory  explains  why  the  use  of  alkaline  waters  is  so  generally 
beneficial  in  gout  and  lithgemia.     Such  fluids  assist  in  regulating  the 
normal  alkaline  reaction  of  the  blood.     This  is  the  line  of  argument 
which   has   been  advanced  by  many   physiological   chemists,   and  it 
applies  in  equal  force  to  the  method  of  formation  of  renal  calculi  and 
gravel.     The  acidity  of  the  urine  is  increased  by  a  meat  diet  and  re- 
duced by   a  vegetable   diet.     With  the  latter  it  may  even  become 
strongly     alkaline.     Whether     we     adopt    the    theory     of     deficient 
oxidation  or  of  diminished  alkalinity  of  the  blood,  the  indications  for 


GOUT  719 

dietetic  treatment  of  gout  are  the  same  —  namely,  reduction  of  proteid 
food  and  increase  of  vegetable  food.  It  does  not  follow  that  proteids 
must  be  given  up  entirely  in  all  cases  of  gout,  but  they  should  be  so 
restricted  that  the  normal  balance  of  the  metabolism  of  the  blood  shall 
be  restored.  It  will  be  found  necessary  for  those  who  live  luxurious 
and  idle  or  sedentary  lives  to  relinquish  proteid  food  altogether,  while 
those  who  are  accustomed  to  take  active  muscular  exercise  may  be 
allowed  animal  food  in  very  moderate  quantity  once  a  day. 

Dietetic  Treatment. —  Although  no  one  food  is  invariably  injurious 
at  all  times,  it  is  almost  universally  agreed  that  for  the  gouty,  fat 
and  proteids  should  be  greatly  restricted  and  saccharine  food  entirely 
prohibited. 

It  may  be  established  as  a  general  rule  that  the  diet  of  the  gouty 
should  consist  principally  of  easily  digested  fresh  green  vegetables 
and  sometimes  certain  fruits,  in  addition  to  which  a  moderate  quan- 
tity of  lean  meat  (beef,  lamb,  and  mutton)  may  be  eaten  to  prevent 
the  necessity  of  taking  an  excessively  bulky  diet,  which  in  order  to 
furnish  sufficient  nitrogen  for  the  needs  of  the  body  would  unduly 
tax  the  digestive  system.  Fruit  is  less  likely  to  disagree  if  taken  by 
itself,  not  with  sugar  or  other  food.  Luff,  of  London,  believes  that 
the  mineral  salts  of  such  vegetables  as  spinach,  turnip-tops,  Brussels 
sprouts,  string  beans,  cabbage,  and  celery  act  chemically  in  preventing 
formation  of  gouty  deposit  in  the  tissues  by  increasing  the  solubility 
of  sodium  biurate  and  retarding  the  conversion  of  quadriurates  into 
biurates. 

It  is  a  serious  mistake  to  prescribe  any  treatment  for  the  gouty 
which  tends  to  lower  the  general  vitality  of  the  system  too  much. 
The  diet,  therefore,  should  be  adjusted  so  as  to  secure  the  right  pro- 
portion of  the  different  classes  of  foods.  Atonic  cases  require  a  gen- 
erous diet  with  more  proteid. 

Gout  is  often  combined  with  excessive  corpulency,  and  when  this 
is  the  case  no  chronic  disease,  with  the  exception,  perhaps,  of  dia- 
betes, requires  more  strict  regulation  of  the  diet  and  hygiene  of  the 
patient.  While  it  is  undesirable  to  allow  animal  food  in  large  quan- 
tities in  gout,  it  is  also  true  that  many  vegetables  are  fattening,  and  if 
the  diet  is  too  restricted  in  both  these  classes  of  foods  the  obese  patient 
suffers  from  lack  of  nutrition,  and  digestion  becomes  still  further  im- 
paired in  consequence.  It  is  best  in  these  cases  to  adopt  a  "reduc- 
tion" treatment  for  the  corpulency  (p.  708)  for  a  few  months,  and 
give  a  proteid  diet,  for  the  gout  will  often  improve  of  itself  as  obesity 
lessens. 

The  theory  has  been  held  that  very  little  fat  should  be  eaten  by 


720        DISEASES  ESPECIALLY   INFLUENCED  BY  DIET 

the  gouty,  for  it  fixes  oxygen  which  would  otherwise  complete  the 
oxidation  of  proteids,  and  hence  favors  accumulation  of  waste 
products.  On  the  other  hand,  it  is  held  that  the  accumulation  of  uric 
acid  is  not  due  to  lessened  oxidation,  but  that  it  is  increased  by  proteid 
metabolism,  and  its  elimination  by  the  kidneys  is  promoted  by  fats. 
Clinically,  however,  it  is  found  best  to  control  the  use  both  of  proteids 
and  fats. 

Sugars,  gelatinous  material,  and  fats  all  tend  to  retard  the  com- 
plete combustion  of  proteid  food,  being  "  tissue  sparers,"  and  the 
latter  therefore  remains  in  an  imperfectly  oxidized  condition  which 
may  give  rise  to  uricaemia.  The  combination  in  excess  of  these  classes 
of  foods,  therefore,  is  particularly  injurious  in  gout.  On  the  other 
hand,  Ebstein  favors  the  use  of  fat  in  moderation,  on  the  ground  that 
it  appeases  the  appetite  and  makes  the  consumption  of  a  large  quan- 
tity of  carbohydrates  unnecessary.  If  fat  is  allowed  at  all  in  the  diet, 
it  is  best  to  give  it  in  very  small  amount ;  otherwise  it  interferes  with 
the  digestion  in  the  stomach  and  tends  to  augment  the  dyspepsia 
'  which  is  so  common  in  gouty  subjects.  It  will  be  borne  better  in  those 
cases  which  are  not  complicated  by  a  tendency  to  obesity. 

In  the  dietetic  management  of  gout  in  robust  subjects  it  is  of 
quite  as  much  importance  to  reduce  the  quantity  of  food  consumed 
as  -to  restrict  the  variety.  Such  patients  should  be  made  to  restrain 
a  too  vigorous  appetite,  and  especially  the  eating  of  food  between 
meals,  for,  as  Balfour  says  (The  Senile  Heart),  "there  is  nothing 
so  destructive  of  gastric  comfort  as  the  continual  pecking  induced 
by  gouty  bulimia."  They  should  never  be  allowed  to  eat  to  complete 
satiety  at  meals,  and  all  rich  sauces,  pastry,  and  strong  condiments  and 
fried  food  should  be  avoided.  The  majority  of  gouty  patients  have 
been  in  the  habit  for  a  long  time  of  eating  too  much  meat,  and  some 
of  them  of  partaking  too  freely  of  carbohydrates.  Overeating  is  al- 
most as  bad  for  patients  as  drinking  too  much.  "  Gout  is  evidence  of 
an  overfed,  overworked,  and  consequently  clogged  machine"  (Osier). 
As  Bence  Jones  says :  "  It  is  best  to  allow  a  minimum  of  albuminous 
food  to  produce  the  least  amount  of  uric  acid  and  a  minimum  of  car- 
bohydrates, in  order  to  give  the  uric  acid  formed  opportunity  to  be 
oxidized  as  much  as  possible." 

When  an  acute  exacerbation  of  gout  occurs  it  is  necessary  to  curtail 
all  variety  in  diet,  and  put  the  patient  upon  light  farinaceous 
food  with  abundant  diluents,  alkaline  waters,  and  weak  tea.  Gruels 
of  sap-o.  arrowroot,  or  barley  may  be  given,  with  bread  or  toast.  When 
iho  fever  subsides  and  the  acute  symptoms  abate,  bouillon,  clam 
juice,  simple  broths  made  of  lean  mutton  or  chicken  with  rice,  may 


GOUT  721 

be  allowed.  Later,  a  little  whitefish  or  breast  of  chicken.  Eed  meat 
should  be  given  only  when  really  necessary,  for,  as  Garrod  says  of  it, 
"everything  beyond  what  is  absolutely  required  for  the  nourishment 
of  the  body  only  feeds  the  disease." 

Sir  Dyce  Duckworth's  treatment  of  the  acute  form  of  the  disease 
is  briefly  as  follows:  he  recommends  such  substances  as  rice,  bread, 
arrowroot,  sago,  tapioca  pudding,  semolina,  milk,  weak  tea,  and  in- 
fusion of  cocoa  nibs.  Later,  chicken  broth  may  be  given,  followed 
by  fish  and  a  mealy  roasted  potato.  Xo  meat  should  be  given  until 
all  acute  symptoms  are  over,  and  then  it  should  be  allowed  but  once 
a  day.  Elderly  persons  may  have  a  little  dilute  whisky  or  brandy, 
not  to  exceed  two  ounces  per  diem.  He  also  favors  the  use  of  hot 
water,  as  in  the  treatment  of  dyspepsia,  but  discountenances  the 
eating  of  fruits,  especially  with  sugars. 

When  the  acute  attack  subsides  and  chronic  gout  supervenes  Gar- 
rod  replaces  the  farinaceous  diet  gradually  by  fruit,  fish,  fowl,  and 
finally  by  meat,  but  any  dishes  containing  free  acids  or  sweets  are 
liable  to  cause  a  relapse. 

Diet  for  the  Gouty  Diathesis  and  Chronic  Gout 

In  the  following  dietary  a  liberal  variety  of  foods  will  be  found, 
some  of  which  may  be  selected  and  changed  from  time  to  time  ac- 
cording to  need  in  the  intervals  between  the  exacerbations  or  in 
chronic  gout.  Should  an  acute  attack  occur  at  any  time  in  the 
course  of  the  disease,  the  diet  should  at  once  be  curtailed,  as  described 
above  (p.  718).  The  number  of  dishes  allowed  at  any  one  meal  should 
be  few.  In  dealing  with  any  case  of  chronic  gout  for  the  first  time 
it  is  injudicious  to  make  radical  changes  in  the  diet  too  suddenly. 

Soups. —  Soup  should  be  free  from  all  fat,  and  is  better  made  of 
vegetables  than  meat,  and  purees  of  potatoes,  celery,  etc.,  may  be 
recommended.  If  the  taste  of  meat  is  desired,  as  suggested  by 
Yeo,  it  is  best  imparted  to  the  soup  by  one  of  the  meat  extracts 
which  contain  simply  the  highly  flavored  extractive  matter  without 
contributing  to  the  bulk  of  proteid  food.  A  teaspoonful  or  two  of 
Valentine's  meat  juice  or  Liebig's  extract  of  meat  in  a  half  pint  of 
vegetable  soup  accomplishes  this  result. 

Milk. —  Milk  disagrees  with  some  gouty  subjects,  but  in  those  who 
digest  it  well,  if  it  be  not  too  rich  in  fat  or  if  taken  skimmed  or 
diluted,  it  forms  an  excellent  food.  Many  are,  however,  opposed 
to  its  use  in  any  form,  even  when  its  alkalinity  is  increased  by  the 
admixture  of  alkaline  waters  or  a  few  grains  of  bicarbonate  of  sodium. 
Yeo  gives  a  small  salt-spoonful  each  of  potassium  bicarbonate  and 


722          DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

common  salt  in  a  breakfast-cupful  of  hot  milk  and  water.  An  ex- 
clusive milk  diet  sometimes,  but  not  often,  aids  those  who  are  robust 
and  young,  but  is  injurious  to  older  patients. 

Cheese,  being  a  concentrated  proteid  food,  should  not  be  eaten. 

Egg8- —  Garrod  allows  eggs  and  bacon  for  breakfast,  and  Ralfe  rec- 
ommends an  "occasional  savory  omelet."  Eggs  cooked  with  milk 
and  custard  puddings  (unsweetened  except  with  saccharin)  may  prove 
harmless,  but  Senator  is  opposed  to  them  on  account  of  the  fat  and 
lecithin  which  they  contain. 

Shellfish  and  Crustaceans. —  The  soft  part  of  oysters  and  clams 
may  be  eaten,  but  crabs,  lobsters  and  shrimps  may  not  be  allowed, 
least  of  all  in  salads,  owing  to  their  tendency  to  cause  dyspepsia. 

Fish. —  Broiled  or  boiled  fish,  such  as  whiting,  sole,  herring,  weak- 
fish,  butterfish,  trout,  smelts,  porgies,  whitefish,  bass,  shad,  are  per- 
missible for  variety,  but  fish  having  firm  flesh  and  those  which  contain 
considerable  fat  are  not  recommended.  Salmon,  mackerel,  halibut, 
cod,  should  therefore  be  avoided,  although  Garrod  allows  salmon 
served  with  salt  and  Cayenne,  but  without  sauce.  Rich  sauces  should 
not  be  eaten  with  fish  or  salads.  In  lieu  of  them,  a  simple  dressing 
of  an  infusion  of  aromatic  herbs  and  pepper,  or  a  plain  bread  sauce, 
may  be  employed. 

Smoked  and  pickled  fish  are  forbidden.  Fish  roe,  such  as  shad 
roe  and  caviare,  is  admissible. 

Meats. —  Meat  should  not  be  prohibited  entirely  for  months  at  a 
time  in  chronic  gout,  especially  for  a  middle-aged  man,  although  the 
young  may  thrive  better  without  it.  It  should  be  eaten  only  once  a 
day  in  any  case,  and  roasting  or  broiling  is  the  best  form  of  cooking 
it.  Twice-cooked  meats  should  not  be  eaten.  Beef,  mutton,  lamb, 
and  poultry  and  squab  may  be  allowed  sparingly.  Veal,  pork,  game, 
and  potted,  dried,  smoked  (except  ham  or  bacon),  pickled,  or  salted 
meats  are  forbidden.  Only  one  kind  of  meat  should  be  eaten  at  a  meal. 

Fats. —  Fats  should  be  used  sparingly,  and  all  food  fried  or  cooked 
in  grease  is  forbidden.  Fat  meats  are  to  be  avoided,  but  a  little  well- 
cooked  bacon  may  occasionally  be  eaten,  and  butter  may  be  taken  only 
in  moderation.  The  objection  to  the  use  of  fats  and  oils  is  that,  unless 
the  general  nutrition  is  very  poor,  they  interfere  in  gouty  subjects 
with  complete  oxidation  of  proteid  elements.  Cream  should  not  be 
used,  and  very  few  eggs. 

Farinaceous  Food. —  Farinaceous  food  is  allowable,  and  in  the  acute 
stage  of  gout  it  should  constitute  the  main  diet.  Bread  (not  fresh), 
boiled  rice,  puffed  rice,  sago,  tapioca,  oatmeal,  cracked  or  shredded 
wheat,  rolled  oats,  hominy,  Graham  bread,  crackers,  gingersnaps, 


GOUT  723 

macaroni  and  spaghetti  may  all  be  eaten.  Pastry,  cake,  hot  rolls, 
griddle  cakes,  preserves,  and  confectionery  of  all  kinds  are  forbid- 
den. 

Sugar. —  Sugar  has  not  proved  to  be  always  harmful  to  the  gouty, 
but  eaten  with  a  mixed  diet,  especially  with  fruits  or  drunk  with 
wines,  it  undergoes  fermentation  processes  which  are  at  once  delete- 
rious. It  is  generally  admitted  that  sugar  eaten  in  excess  with  other 
food  is  more  injurious  than  fats  in  excess. 

Sweets,  jams,  and  jellies  of  all  kinds  are  forbidden.  When  sugar 
positively  disagrees,  a  little  glycerin  or,  better,  saccharin  or  diabetin 
(levulose)  may  be  substituted  for  it. 

Vegetables. —  Of  vegetables,  although  a  great  variety  are  eaten, 
there  are  a  few  which  are  prohibited  on.  account  of  the  fact  that  they 
contain  oxalic  acid,  which  is  closely  allied  to  uric  acid,  and  which 
produces  oxaluria.  These  are  sorrel,  radishes,  asparagus,  rhubarb, 
tomatoes,  and  spinach.  The  two  latter  are  allowed  by  some  authori- 
ties, however.  Beets  are  forbidden.  Vegetables,  such  as  cabbage, 
onions,  and  old  peas,  beans,  and  corn,  if  they  occasion  flatulence,  must 
be  eschewed.  The  following  may  be  eaten:  French  peas  (petit  pois) 
and  young  French  beans,  string  beans,  Lima  beans,  celery,  young  ten- 
der green  corn,  carrots,  turnips,  parsnips,  well-baked  and  mealy  pota- 
toes (except  sweet  potatoes)  sparingly,  cucumbers,  broccoli,  beet-tops, 
cauliflower,  Brussels  sprouts,  squash,  lettuce,  romaine,  celery,  egg- 
plant, okra,  artichoke.  Salads,  provided  they  are  not  dressed  with 
much  oil,  are  allowable.  Vegetables  which  act  injuriously  on  account 
of  their  acids  (like  tomatoes)  are  made  still  more  harmful  by  being 
cooked  with  sugar. 

Fruits. —  Some  writers  allow  fruits  of  almost  every  kind,  both  raw 
and  cooked,  but  Sir  Dyce  Duckworth  and  many  authorities  declare 
that  fruits  in  general  are  harmful.  The  late  Sir  Andrew  Clarke  for- 
bade their  use  in  toto.  If  they  produce  no  dyspepsia,  and  are  ripe 
and  fresh,  a  few  fruits  may  be  eaten,  such  as  stewed  pears,  or  apples 
stewed,  baked,  or  roasted.  I  am  accustomed  also  to  allow  melons, 
oranges,  pineapples,  and  peaches.  All  those  fruits  which  contain 
large  quantities  of  sugar,  such  as  grapes,  figs,  bananas,  prunes,  etc., 
should  be  forbidden,  as  also  acid  fruits,  especially  strawberries.  No 
fruits  cooked  with  sugar  are  allowable.  Garrod  expressly  forbids 
all  stone-bearing  fruits,  and  says  that  subacid  fruits  furnish  alkaline 
salts  that  split  up  in  the  blood  and  reappear  in  the  urine,  chiefly  as 
potassium  carbonate,  and  stimulate  the  kidneys. 

Fothergill  wrote :  "  The  potash  in  the  strawberry  renders  its  juice 
a  desirable  drink  for  the  gouty  and  for  strumous  children/'  but  there 


DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

are  patients  who  cannot  eat  half  a  dozen  strawberries  without  an 
exacerbation  of  inflammation  in  a  gouty  joint. 

If  any  fruit  is  eaten  it  should  not  be  in  connection  with  other  food 
or  with  sugar.  Hence  all  candied  fruits  are  proscribed.  Nuts  are 
forbidden. 

Pickles,  vinegar,  spices,  strong  condiments,  salted  foods,  mush- 
rooms, and  truffles  should  all  be  forbidden. 

Eating  between  meals  and  at  irregular  intervals  is  injurious.  Fresh 
air  and  exercise  are  more  needed  than  extra  luncheons  of  bouillon, 
broths,  wines,  etc. 

Ealfe  gave  the  following  menu  for  breakfast  and  lunch : 

Breakfast. —  A  poached  egg,  bacon,  or  fresh  fish,  tea  (chocolate  and 
cocoa  disagree)  without  milk  or  sugar. 

Light  Lunch. —  A  clear  soup,  vermicelli  or  julienne,  sandwiches, 
cold  meat  with  salad. 

Dinner  is  to  be  eaten  not  too  late,  and  fully  three  hours  before 
retiring. 

Sir  Dyce  Duckworth  prescribes  the  following  excellent  menu  for 
goutiness  or  chronic  gout  in  Allbutt's  System  of  Medicine : 

"  Six  or  eight  ounces  of  hot  or  cold  water  may  be  taken  half  an 
hour  before  breakfast.  Breakfast  should  consist  of  one  or  two  ounces 
of  well-toasted  stale  bread  without  butter,  grilled  whitefish,  grilled 
mutton  chop  or  beefsteak,  or  cold  chicken,  game,  beef,  tongue,  or 
lean  ham.  One  or  two  small  cups  of  tea  or  coffee,  with  a  little 
skimmed  milk  and  without  sugar  may  be  taken.  Saccharin  may  be 
used  as  a  sweet  flavoring  agent,  but  is  commonly  disliked.  Six  ounces 
of  bouillon  or  clear  soup  may  be  taken  by  weakly  patients  between 
breakfast  and  luncheon,  and  a  gluten  or  almond  biscuit  with  it.  For 
luncheon  order  cold  meat  or  a  poached  egg  with  spinach  or  lettuce,  or 
other  green  vegetable,  as  water  cress  and  mustard  and  cress,  or  a  small 
omelet.  Crust  of  bread  or  hard  biscuit  in  small  amount  is  allowable 
and  a  small  quantity  of  fresh  butter.  A  glass  of  good  Bordeaux  or 
Moselle  wine  (dry)  may  be  taken  with  as  much  water.  A  cup  of  tea 
with  a  little  skimmed  milk  and  a  rusk  or  gluten  biscuit  may  be  taken 
in  the  afternoon.  For  dinner  no  soup  is  to  be  taken,  as  a  rule,  but 
occasionally  about  eight  ounces  of  a  thin  consomme  may  be  allowed, 
then  a  little  grilled  or  boiled  fish,  without  starchy  or  fatty  sauces,  but 
flavored  sometimes  with  anchovy  or  some  other  sauce,  oysters,  or. 
caviare,  a  little  grilled  or  roasted  meat,  mutton,  game,  or  fowl,  with  a 
small  proportion  of  fat,  green  vegetables,  and  some  stewed  fruit  fla- 
vored with  saccharin  or  made  less  tart  by  the  addition  of  half  a  tea- 
spoonful  of  Eochelle  salt.  Two  classes  of  claret  or  of  a  dry  Moselle 


GOUT  725 

diluted  with  water  are  allowable.  Later  in  the  evening  a  cup  of  hot 
weak  tea,  without  milk,  or  as  much  hot  water  should  be  taken." 

Beverages. —  Water. —  It  has  been  stated  above  that  to  favor  the 
washing  of  waste  matter  from  the  system  it  is  desirable  to  drink  con- 
siderable quantities  of  fluid,  and  gouty  patients  who  are  corpulent 
usually  perspire  with  freedom;  their  urine  therefore  becomes  concen- 
trated, and  there  is  a  tendency  to  the  precipitation  in  it  of  uric  acid, 
urates,  and  oxalate  of  lime.  It  should  be  remarked  that  the  presence 
of  uric  acid  in  the  urine  does  not  always  indicate  an  excess  of  that 
acid,  for  it  may  happen  that  the  urine  is  too  concentrated  or  other- 
wise altered  to  hold  it  in  solution,  and  hence  precipitation  results. 
An  excess  of  acid  phosphate  may  combine  with  the  sodium  and  potas- 
sium which  are  necessary  to  hold  the  uric  acid  in  solution  in  the  form 
of  urates,  and  it  is  deposited  in  insoluble  crystals.  Copious  draughts 
of  hot  water  at  bedtime  or  on  rising  in  the  morning  are  often  pre- 
scribed, but  it  is  doubtful  whether  the  temperature  of  the  water  makes 
any  difference  in  the  desired  result  so  long  as  plenty  of  fluid  is 
imbibed. 

Fluid  should  be  drunk  half  an  hour  before  meals,  when  the  stom- 
ach is  empty.  Besides  serving  to  cleanse  the  mucous  membrane  of 
the  alimentary  canal,  the  diuretic  action  of  water  is  greater  when 
absorbed  at  such  times. 

Sir  Dyce  Duckworth  holds  somewhat  different  views  in  regard  to 
water  drinking,  although  he  does  not  make  clear  his  reasons  for  so 
doing.  He  says :  "  I  feel  sure  that  Sydenham  was  right  in  condemn- 
ing water  drinking  for  the  gouty.  '  Water  alone  is  bad  and  danger- 
ous, as  I  know  from  personal  experience.  When  taken  as  the  regular 
drink  from  youth  upward  it  is  beneficial/ >!  He  prefers  to  allow  a 
moderate  quantity  of  wine  —  from  four  to  six  ounces  of  good  sound 
Bordeaux,  and  adds :  "  The  least  excess  is  harmful,  but  a  little  good 
wine  is  better  for  most  gouty  persons  than  water  drinking,  espe- 
cially after  middle  life."  This  was  written  for  Englishmen  in  the 
upper  classes,  whose  ordinary  consumption  of  wine  is  greater  than 
that  of  Americans  in  the  same  social  position.  Much  depends  upon 
one's  previous  habits  of  life,  and  in  this  country  examples  of  gout  may 
be  found  not  rarely  among  patients  who  have  never  been  in  the  habit 
of  drinking  alcoholic  beverages  daily,  and  such  persons  do  best  to  con- 
tinue to  abstain  from  them  entirely. 

Tea,  Coffee,  etc. —  Tea  and  coffee  are  admissible  among  beverages 
for  the  gouty,  and  it  will  be  found  that  they  are  less  likely  to  cause 
dyspepsia  if  taken  qu'ite  weak  without  sugar.  A  quarter  of  a  grain  of 
saccharin  may  be  added  instead.  Senator,  of  Berlin,  on  the  contrary 


726          DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

forbids  tea  and  coffee,  and  prescribes  "acorn  coffee."  Infusion  of 
cocoa  nibs  is  less  to  be  recommended  on  account  of  the  fat  which  it 
contains.  Esbach  states  that  he  has  found  oxalic  acid  in  it  also, 
amounting  sometimes  to  0.4  per  cent.  Chocolate  is  forbidden. 

Alcoholic  Drinks. —  In  this  country  it  is  the  part  of  wisdom  to 
abstain  entirely  from  alcohol,  but  many  persons  are  so  habituated  to 
its  use  that  they  are  unwilling  to  abandon  it,  and  a  compromise  must 
be  effected.  It  is  easier  for  them  to  give  up  certain  foods  than  drink. 
With  regard  to  the  use  of  alcoholic  beverages  it  is  their  acid  and 
saccharine  ingredients  rather  than  the  alcohol  itself  which  disagree. 
Strong  liquors,  diluted,  may  not  be  injurious,  but  nothing  is  worse 
than  rich  sweet  wines  and  malt  liquors. 

Patients  who  are  able  to  lead  active  outdoor  lives  may  drink  more 
alcohol  than  those  of  sedentary  habits,  without  augmenting  their 
symptoms.  In  general  the  quantity  consumed  is  as  important  as  the 
quality,  and  should  be  prescribed  definitely  and  kept  within  bounds. 

It  is,  however,  true  that  alcohol  in  all  forms  lessens  the  elimina- 
tion of  tissue  waste,  and  decreases  the  volume  of  urea  and  uric  acid 
excreted.  According  to  Pfeiffer,  both  beer  and  wine  may  lessen  this 
volume  by  one-half;  on  the  following  day  it  is  increased,  and  subse- 
quently diminished  again.  The  longer  wines  have  been  fermented, 
or  the  more  complete  the  conversion  of  the  sugar  to  alcohol,  the  less 
hurtful  they  become  to  the  gouty. 

If  free  perspiration  exists  in  warm  weather,  and  active  diuresis  as 
well,  alcoholic  drinks  of  all  kinds  are  less  harmful.  Whatever  form 
of  alcohol  be  taken,  it  should  be  drunk  to  the  exclusion  of  all  others, 
for  mixtures  are  particularly  injurious. 

Strong  beer,  ales,  porter,  stout,  all  malt  extracts,  and  sweet  cider 
are  absolutely  prohibited.  Sir  Henry  Thompson  and  Germain  See 
regard  cider  as  beneficial  as  a  solvent  of  uric  acid,  but  by  others  it  is 
looked  upon  as  injurious  on  account  of  the  malate  of  potassium  which 
it  contains,  and  which  it  is  claimed  favors  the  formation  of  uric 
acid  (Yeo).  The  alcoholic  drinks  which  are  tolerated  best  by  the 
gouty  are  good  French  Cognac  or  old  Scotch  whisky,  well  diluted  with 
water,  Apollinaris,  or  soda  water.  Scotch  whisky  is  by  many  found 
to  agree  better  than  any  other  variety.  Weak  brandy  and  soda  may 
be  substituted,  or  unsweetened  Plymouth  gin. 

There  are  some  wines  which  should  be  prohibited  absolutely,  among 
them  all  which  are  re-enforced  by,  or  which  contain,  a  large  pro- 
portion of  saccharine  material.  Strong  port,  sherry,  sweet  cham- 
pagne, Madeira,  Canary,  claret,  and  Burgundy  are  comprised  in  this 
list. 


GOUT  727 

Port  wine  has  even  required  the  reputation  of  being  a  primary 
factor  in  producing  gout,  when  a  hereditary  diathesis  does  not  exist. 
It  is  an  incompletely  fermented  wine  to  which  alcohol  has  been  added 
for  preservation,  and  all  wines  of  this  class  are  the  worst  forms  of 
alcohol  for  the  gouty.  Garrod  says  that  exceptionally  a  sound  sherry, 
Amontillado  or  Manzanilla,  may  be  prescribed.  There  are  patients, 
too,  who  maintain  that  they  do  better  with  port  as  a  daily  beverage 
than  with  any  other  form  of  wine,  but  their  example  would  be  a  very 
unsafe  one  to  follow,  and  their  experience  is  due  to  constitutional 
idiosyncrasy. 

Duckworth  says :  "  Ehenish  wines  are  acid  and  harmful ;  those  of 
the  Moselle  district  are,  however,  less  acid,  and  rather  better  borne. 
Australian,  Californian,  Hungarian,  Greek,  and  other  Mediterranean 
wines  are  too  strong,  and  after  a  time  generally  disagree." 

The  stronger  clarets  containing  more  tannin,  and  all  wines  with 
much  free  acid,  are  injurious. 

Among  the  light  wines  several  may  be  permitted  in  moderation, 
but  they  should  be  diluted  with  an  alkaline  water  in  order  to  neu- 
tralize any  acidity.  Such  wines  should  be  either  bottled  or  drunk 
from  the  cask,  for  newly  bottled  wines  are  more  injurious. 

The  best  Bordeaux  and  lightest  Hungarian  wines,  light  hock  and 
a  still  Moselle,  such  as  Zeltinger,  may  be  drunk,  for  these  wines  are 
quite  thoroughly  fermented,  and  therefore  contain  no  sugar  or  free 
acid,  though  they  have  salts,  such  as  cream  of  tartar.  These  wines 
should  only  be  allowed  in  moderation,  not  over  half  a  pint  in  a  day. 
An  absolutely  dry  champagne  may  sometimes  be  permitted,  or  very 
dilute  and  weak  pure  claret. 

Yeo  says :  "  The  more  distinguished  the  diuretic  effect  of  the 
wine,  the  better,  as  a  rule,  will  it  agree  with  the  gouty/' 

Ealfe's  practice  is  to  allow  no  wine  of  any  sort  with  dinner,  but 
afterwards  two  claret-glassfuls  of  some  light  wine  are  permitted; 
and  he  says  that  a  tablespoonful  of  brandy  in  half  a  tumblerful  of 
water  before  meals  increases  the  secretion  of  gastric  juice.  If  the 
patient  is  weak,  or  suffers  from  insomnia,  he  gives  brandy  or  whisky 
at  bedtime  in  some  effervescing  water.  He  states  that  in  his  expe- 
rience patients  who  long  have  been  habituated  to  the  daily  use  of  port, 
sherry,  or  ale,  often  become  worse  when  a  sudden  change  is  made  to 
claret  or  hock.  In  such  cases  he  advises  changing  gradually  by  sub- 
stituting at  first  a  drier  port  or  sherry.  Usually  such  red  wines  as 
St.  Julien  and  St.  Estephe  are  preferable  to  the  higher  class,  such  as 
Lafitte  or  La  Eose.  ' 

Different   persons   show   peculiar   idiosyncrasies   in   regard   to   the 


728         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

gout-producing  influence  of  certain  wines.  Some  will  always  have 
gouty  inflammation  set  up  within  a  few  hours  in  a  particular  joint  by 
one  form  of  liquor  or  wine  and  not  by  others. 

Saline  Waters. —  Alkaline  and  saline  mineral  waters  have  a  well- 
deserved  reputation  for  benefiting  gout.  Many  persons,  especially 
obese  gouty  subjects,  are  helped  by  taking  one  or  two  "  courses  "  of 
treatment  a  year  for  two  or  three  successive  years  at  Carlsbad  in 
Bohemia,  or  elsewhere.  Carlsbad  water  may  be  drunk  at  home,  four 
or  five  ounces  being  taken  on  rising  in  the  morning,  or  an  equivalent 
of  the  evaporated  salts  —  chiefly  sodium  sulphate. 

The  water  of  the  Kreuzbrunnen  at  Marienbad  has  essentially  the 
same  composition  with  that  of  Carlsbad,  but  contains  more  sodium 
sulphate.  Elderly  persons  may  be  injured  by  a. .too  energetic  use  of 
these  salines,  and  they  should  take  only  milder  alkaline  waters  con- 
taining less  sodium. 

The  German  Fachingen  water  has  proved  very  serviceable.  It  con- 
tains 3.5  per  cent  of  bicarbonate  of  sodium  and  6  per  cent  of  bicar- 
bonate of  lime. 

Celestins  Vichy  is  good  for  strong  patients,  but  not  for  the  feeble  or 
anremic.  It  also  contains  considerable  sodium  bicarbonate,  and  the 
Vals  water  has  more  sodium  carbonate  than  many  alkaline  waters. 
These  waters  favor  the  elimination  of  uric  acid  as  a  salt  rather  than 
in  the  free  state.  Apollinaris  and  Johannis  water  are  good. 

Saratoga  alkaline  water  is  among  the  best  in  this  country  for  gouty 
patients.  It  contains  carbon  dioxide,  sodium  and  alkaline  carbonates, 
and  chlorides. 

The  waters  of  the  St.  Glair  Spring  in  Michigan,  and  those  of  the 
St.  Catherine  Spring  in  Ontario,  are  good  alkaline  salines  for  gout; 
Many  lithia  waters  are  also  recommended,  but  they  contain  little 
lithium.  All  alcoholic  beverages  drunk  by  the  gouty  should  be  well 
diluted,  and  mildly  alkaline  mineral  waters  are  especially  valuable  for 
this  purpose. 

Aids  to  Dietetic  Treatment. —  The  individual  peculiarities  of  di- 
gestion should  be  studied  in  each  case  by  the  physician,  and  the  pa- 
tient thoroughly  examined  in  regard  to  the  minutiae  of  all  his  hygienic 
and  dietetic  habits.  Meals  should  be  taken  at  stipulated  hours  —  the 
breakfast  on  rising,  dinner  not  later  than  seven  o'clock,  and  late 
suppers  should  be  avoided.  Between  the  acute  attacks  it  is  absolutely 
necessary  to  maintain  digestion  in  a  normal  condition.  The  bowels 
should  l)e  kept  open,  and  the  condition  of  the  skin  actively  main- 
tained by  cold  bathing  and  friction.  Exercise  should  be  taken  in  the 
open  air.  The  urine  should  be  examined  frequently,  with  especial 


DIABETES  MELLITUS  729 

reference  to  the  hour  of  the  day  at  which  it  is  passed  and  the  relation 
which  its  composition  bears  to  the  food  eaten. 


DIABETES  MELLITUS 

Nature  of  the  Disease. —  Diabetes  mellitus  is  a  disease  character- 
ized by  the  passage  of  a  large  quantity  of  urine  containing  grape  sugar 
or  glucose  and  usually  of  high  specific  gravity  — 1.032  or  more 
—  excessive  thirst,  and  sometimes  exaggerated  or  perverted  appetite ; 
progressive  emaciation;  muscular  weakness  and  languor.  The  disease 
runs  a  chronic  course,  and  the  majority  of  cases  terminate  fatally  in 
from  two  to  four  years,  although  some  patients  live  20  years  or  more. 
Death  may  result  from  inanition,  "  diabetic  coma  "  or  other  causes. 
The  knowledge  of  the  disease  has  been  aided  by  experimentation 
upon  the  lower  animals,  in  which  diabetes  may  be  produced 
experimentally.  The  treatment  is  almost  entirely  dietetic  and  hy- 
gienic, for  as  yet  no  medicinal  remedy  has  been  found  which  is  cura- 
tive, and  very  few  have  been  discovered  which  are  palliative  in  any 
considerable  number  of  cases.  Diabetes  is  therefore  essentially  a  die- 
tetic disease,  for  although  not  usually  caused  by  errors  in  diet  it  may 
be  so  produced  exceptionally,  and  most  cases  are  more  or  less  ben- 
efited by  dietetic  treatment,  while  some  may  undoubtedly  be  cured 
by  it. 

Diabetes  was  described  more  than  a  century  ago;  and  Kollo  in- 
augurated the  dietetic  treatment  by  withholding  vegetable  food.  In 
1838  Gmelin  and  Tiedemann  established  the  existence  of  the  relation 
between  the  digestion  of  carbohydrates  and  the  formation  of  sugar. 
In  1848  the  eminent  physiologist  Claude  Bernard  first  threw  definite 
light  upon  the  relations  of  the  liver  to  the  consumption  of  sugar  and 
the  formation  of  glycogen,  and  since  that  day  physiologists  and 
clinicians  in  many  countries  have  contributed  extensively  to  the 
knowledge  of  the  disease.  The  method  of  production  and  elimination 
of  the  sugar  and  the  influence  of  the  disease  upon  general  nutrition  is 
understood,  but  its  exciting  cause  and  the  fundamental  reason  for  the 
interesting  departure  from  the  normal  metabolism  of  starchy  foods 
which  is  its  basis  is  still  unknown. 

Causation. —  The  influence  of  heredity  may  be  traced  as  a  factor  in 
about  one-third  of  all  cases.  The  disease  may  arise  in  any  climate 
and  in  any  age  with  either  sex,  but  it  is  commonest  in  males  as  com- 
pared with  females  in  the  proportion  of  three  to  one.  In  the  latter  it 
occurs  oftenest  between  twenty  and  forty  years;  in  males,  between 
thirty  and  forty-five  years.  It  is  somewhat  more  common  among  the 


730         DISEASES  ESPECIALLY   INFLUENCED  BY  DIET 

wealthy  than  the  poor  because  of  sedentary  habits  combined  with  over- 
indulgence in  eating.  The  obese,  particularly  those  who  have  much 
omental  fat,  are  more  liable  to  diabetes  than  are  thin  persons  who  are 
more  active. 

Among  the  various  determining  causes  of  the  disease  have  been 
reported  blows  and  shocks  affecting  particularly  the  nervous  sys- 
tem, injuries  to  the  back  of  the  head  and  blows  over  the  liver,  as 
well  as  general  concussion,  such  as  that  produced  in  railway  accidents ; 
exposure  to  cold,  wet,  and  fatigue;  convalescence  from  fevers;  emo- 
tional strain,  worry,  mental  fatigue,  and  anxiety.  Tumors  and  hemor- 
rhage at  the  base  of  the  brain  and  circumscribed  lesions  of  the  floor 
of  the  fourth  ventricle  have  been  known  to  occasion  the  disease.  A 
number  of  cases  are  associated  with  disease  of  the  pancreas. 

Overindulgence  in  Food. —  True  diabetes  is  not  to  be  traced  to 
any  constant  dietetic  factor,  although  inordinate  eating  of  candy,  choc- 
olate, preserves,  raisins,  sweet  fruits,  confections,  etc.,  may  occasionally 
cause  temporary  glycosuria. 

G.  P.  Fowler  wrote :  "  I  have  been  in  the  habit  of  supplying  my 
classes  with  saccharine  urine  simply  by  taking  about  four  ounces  of 
dried  dates  or  about  a  tablespoonful  of  pulverized  glucose  upon  a  fast- 
ing stomach." 

The  order  of  harmfulness  of  carbohydrates  in  diabetes  may  be 
stated  as  follows,  commencing  with  the  most  injurious:  1,  glucose; 
2,  saccharose ;  3,  starch ;  4,  lactose ;  5,  inulin ;  6,  levulose. 

Sugar  may  be  present  in  the  urine  in  the  proportion  of  from  five 
to  ten  parts  per  thousand,  but  so  long  as  its  occurrence  in  this  manner 
is  of  brief  duration,  and  so  long  as  it  immediately  may  be  traced  to 
indiscretion  in  the  abuse  of  saccharine  foods,  it  is  of  little  practical 
significance.  In  transient  glycosuria  the  ingestion  of  excess  of  cane 
sugar  does  not,  according  to  Worm-Muller  and  others,  produce  glucose 
in  the  urine,  but  saccharose.  In  diabetes  lactose  reappears  in  the 
urine  as  glucose,  but  under  normal  conditions  if  eaten  in  excess  it 
causes  a  transient  lactosuria. 

Ac-hard  and  Weil  proved  experimentally  that  lactose  injected  hypo- 
dermically  in  solution  is  not  assimilated  in  diabetes,  and  a  milk  diet 
almost  always  increases  the  glycosuria,  in  spite  of  which  the  patient 
may  gain  weight,  owing  to  improved  digestion. 

Relation  to  Gout  and  Other  Diseases. —  Occasionally  obese  persons 
past  fifty  years  of  age  who  are  gouty  may  present  the  symptom  of 
glycosuria  without  other  accompanying  manifestations  of  diabetes, 
such  as  emaciation  and  debility.  This  symptom  may  persist  for  a 
number  of  years  and  end  in  recovery,  or  the  patient  may  die  of  some 


DIABETES   MELLITU8  731 

mtercurrent  disease  in  no  way  connected  with  diabetes.  In  a  long 
series  of  cases  of  diabetes  reported  by  Ord,  gout  occurred  in  over  one- 
third,  and  in  some  there  was  arthritis. deformans.  In  these  cases  not 
only  does  the  urine  contain  sugar  in  excess,  but  the  urea  and  uric 
acid  are  largely  increased.  It  is  interesting  to  remark  in  this  connec- 
tion that  similar  dietetic  treatment  benefits  obese  and  diabetic  pa- 
tients, for  they  both  live  best  upon  a  proteid  diet  with  alkalies.  Dia- 
betes is  also  often  associated  with  neuralgia,  phthisis,  and  hepatic  con- 
gestion. There  is  no  one  form  of  disease  of  the  liver  or  pancreas  of 
which  diabetes  is  a  uniform  or  frequent  accompaniment.  In  about 
one-third  of  the  cases  a  history  is  obtainable  of  mental  strain,  worry 
or  overwork,  and  in  about  one-third  there  is  a  history  of  alcoholism, 
which,  however,  may  be  incidental. 

Physiological  Experiments. —  Claude  Bernard  was  the  first  to  de- 
termine accurately  the  amount  of  sugar  normally  present  in  the  blood. 
According  to  his  estimate,  when  this  quantity  does  not  exceed  three 
parts  in  one  thousand,  the  limits  of  health  are  not  surpassed,  and 
sugar  does  not  appear  in  the  urine,  as  it  promptly  does  when  the 
proportion  is  increased. 

He  fed  animals  heavily  upon  sugar,  killed  them,  and  examined  the 
blood  from  various  blood  vessels.  In  this  manner  he  ascertained 
that  much  sugar  is  destroyed  by  the  passage  of  the  blood  through 
the  lungs,  but  he  also  found  it  to  be  carried  by  the  hepatic  vein, 
whereas  the  portal  vein  contained  a  mere  trace.  He  demonstrated 
that  the  liver,  excised  from  the  body  and  washed  free  of  all  blood 
by  a  stream  of  water  injected  through  the  portal  vein,  would,  after 
standing  for  a  few  minutes,  still  yield  sugar.  He  thus  proved  that 
the  liver  is  capable  of  forming  sugar  by  some  process  which  is  con- 
tinued independently  of  its  blood  supply.  He  next  searched  for  the 
source  of  the  sugar  formed  by  the  liver,  and  discovered  the  sub- 
stance, to  which  he  gave  the  name  of  "glycogen."  Glycogen,  or 
"  animal  starch,"  is  a  normal  ingredient  of  the  liver  cells,  in  which  it 
is  stored  in  the  form  of  amorphous  granules  around  their  nuclei. 
When  treated  by  diastatic  ferments  or  boiled  with  dilute  mineral  acids, 
it  is  converted  into  a  grape  sugar  or  glucose.  Hensen,  of  Kiel,  dis- 
covered glycogen  independently  of  Bernard  and  at  nearly  the  same 
time.  This  substance,  which  is  isomeric  with  starch,  is  normally  pres- 
ent in  the  skeletal  muscles  as  well. 

Bernard  also  found  that  the  quantity  of  sugar  which  he  could  col- 
lect from  the  hepatic  vein  at  any  time  did  not  increase  when  the 
animal  was  fed  upon  a  large  amount  of  sugar;  this  circumstance  led 
him  to  argue  that  the  liver  arrests  the  sugar  ingested  on  its  way  to 


732          DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

the  general  circulation,  and  thus  acts  as  a  regulator  of  the  amount 
of  sugar  contained  in  the  blood. 

Man  takes  his  food  at  comparatively  infrequent  intervals,  and  it 
is  important  that  the  energy  derived  from  the  ingestion  of  a  large 
meal  of  carbohydrates  should  not  be  expended  immediately,  but 
should  be  stored  in  some  form  which  will  enable  it  to  be  used  grad- 
ually in  the  intervals  between  digestion  of  meals,  and  in  any  emer- 
gency when  food  is  'withheld  for  a  longer  time  than  usual.  The  liver 
affords  this  means  of  storing  a  considerable  amount  of  energy  by 
converting  the  sugar  —  brought  to  it  in  the  portal  system  which  has 
been  absorbed  from  the  intestinal  wall  —  into  glycogen,  a  temporary 
product.  In  this  manner  an  excess  of  sugar  ingested  or  an  excess  of 
sugar  derived  from  the  digestion  of  starchy  food  is  normally  kept 
from  entering  the  circulation  immediately,  and  its  use  is  economized 
by  holding  it  back  until  it  is  required  for  force  production.  The  ulti- 
mate destination  of  the  sugar  reformed  from  the  glycogen  of  the  liver 
is  that  it  is  consumed  either  in  the  capillaries  or  intercellular  spaces 
or  in  the  muscular  and  other  tissues  of  the  body  by  obscure  ultimate 
processes  of  nutrition,  which  result  in  its  splitting  up  into  carbonic 
acid  and  water  with  the  evolution  of  heat.  In  support  of  this  view 
Claude  Bernard  proved  that  there  was  less  sugar  in  systemic  venous 
blood  than  in  arterial  blood. 

Bernard  extracted  with  glycerin  a  diastatic  ferment  from  the  liver 
and  blood,  which  he  supposed  had  the  function  of  converting  the 
glycogen  into  glucose ;  this  action  he  called  the  "  glycogenic  "  func- 
tion of  the  liver.  The  sugar  absorbed  from  the  intestines  and  arrested 
in  the  liver  he  supposed  to  be  there  converted  into  glycogen  by  the 
glycogenic  ferment.  Glycogen  may  be  formed  in  part  by  dehydra- 
tion of  sugar  derived  from  metabolism  of  proteid  food.  When  dia- 
betes is  once  established,  the  elimination  of  sugar  in  the  urine  may 
sometimes  continue  in  both  man  and  animals  kept  upon  an  exclusive 
proteid  diet. 

The  foregoing  experiments  have  given  rise  to  three  opposing  theo- 
ries regarding  the  origin  of  glycosuria,  which  are  as  follows : 

1.  It  is  due  to  impaired  glycogenic  function,  and  the  sugar  taken 
as  a  food  is  at  once  passed  into  the  general  circulation  unaltered. 

2.  It  is  cine  to  increased  glycogenic  function;   there   is  an  over- 
production of  sugar  from  the  glycogen,  the  latter  being  derived  both 
from  sugar  and  peptones,  and  the  newly  formed  sugar  is  swept  into 
the  blood. 

3.  The  conditions  of  absorption  of  carbohydrates  and  of  the  func- 
tional activity  of  the  liver  may  remain  normal,  arid  yet  the  final  com- 


DIABETES  MELLITUS  733 

bustion  of  sugar  by  the  tissues  or  its  assimilation  by  them  may  be 
imperfect  and  lead  to  its  accumulation  in  the  blood  and  subsequent 
appearance  in  the  urine. 

The  three  conditions  mentioned  above  imply  either  diminished 
activity  'of  the  liver,  increased  activity  of  the  liver,  or  a  normal  liver, 
the  fault  being  in  other  tissues  of  the  body.  Either  one  may  give 
rise  to  the  presence  of  an  abnormal  amount  of  sugar  in  the  blood 
(glycohasmia),  which  is  excreted  by  the  kidneys  (glycosuria). 

It  is  probable,  however,  that  in  the  majority  of  cases  the  primary 
difficulty  is  to  be  found  in  altered  metabolism  in  the  liver  or  pancreas. 

The  essential  difference  between  the  theories  of  Bernard  and  Pavy 
in  regard  to  the  glycogenic  function  of  the  liver  concerns  merely  the 
final  destination  of  the  glycogen.  Both  agree  as  to  the  primary  con- 
version of  sugar  from  the  portal  vein  into  glycogen,  but  while  Bernard 
believed  that  the  glycogen  is  reformed  into  glucose  and  consumed  in 
the  tissues,  Pavy  held  that  the  normal  use  of  glycogen  is  in  the  forma- 
tion of  fat. 

Pavy  propounded  another  ingenious  theory  to  account  in  part 
for  diabetes,  which  is  that  the  intestinal  epithelium  of  the  villi  ordi- 
narily exerts  a  sort  of  glandular  control  over  the  sugar  absorbed  from 
the  bowel,  and  converts  it  into  glycogen  and  fat  as  it  reaches  the 
blood.  Failure  to  perform  this  function  results  in  the  production  of 
glycosuria.  This  failure,  Pavy  held,  is  due  primarily  to  faulty  nerve 
action  affecting  the  caliber  of  the  arterioles  and  capillaries  and  hyper- 
oxidation,  which  favors  the  too  rapid  conversion  of  carbohydrates 
into  glucose,  causing  glycosuria.  This  theory  has  been  somewhat 
severely  criticised  by  Paten,  and  is  opposed  to  Seegen's  views,  but  it 
does  not  exclude  belief  in  the  storage  of  carbohydrates  as  glycogen  in 
the  liver  —  it  is  merely  accessory  to  it. 

The  Pancreas  and  Diabetes. —  Extirpation  of  the  pancreas  in  man 
has  been  shown  by  the  late  William  T.  Bull,  of  New  York,  to  some- 
times produce  diabetes,  and  experimental  extirpation  of  this  gland  in 
dogs  has  the  same  result.  In  many,  but  not  all  fatal  cases  of  diabetes, 
more  or  less  pancreatic  disease,  usually  of  the  nature  of  chronic  inter- 
stitial inflammation,  has  been  observed.  The  gland  is  known  to  pro- 
duce an  internal  secretion  —  i.  e.,  a  secretion  passed  into  the  circula- 
tion, which  is  a  glycolytic  ferment  —  and  when  the  gland  is  diseased 
this  ferment  is  reduced  in  quantity,  sugar  fails  of  conversion  to  glyco- 
gen, and  diabetes  results.  Opie  believes  that  the  islands  of  Langer- 
hans  are  the  structural  portions  of  the  pancreas  concerned  with  the 
production  of  the  ferment,  and  degenerative  changes  have  been  ob- 
served in  diabetes  in  these  islands  of  polygonal  cells  which  are  supplied 


73-i         DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

with  a  rich  capilliary  network.  Atrophy  and  fibroid  overgrowth  of 
the  pancreas  are  especially  prone  to  cause  diabetes. 

The  Nervous  System  and  Diabetes. —  It  is  a  curious  fact  that  the 
irritation  or  puncture  of  a  very  circumscribed  area  in  the  floor  of  the 
fourth  ventricle  in  the  medulla  is  followed  by  the  appearance  of  sugar 
in  the  urine.  This  spot  is  called  the  "  diabetic  center/'  and  it  is  in 
close  relation  with  the  sympathetic  and  vasomotor  nerves  that  con- 
trol the  capacity  of  the  hepatic  blood  vessels.  Glycosuria  is  also  ob- 
served in  man  after  the  inhalation  of  chloroform  and  in  animals  after 
the  inhalation  of  irritant  vapors  and  after  stimulation  of  the  pneu- 
mogastric  nerve.  If  the  vagus  nerve  be  divided  in  the  neck,  or  if  the 
spinal  cord  be  divided  above  the  origin  of  the  great  sympathetic 
nerve,  diabetes  may  result.  Bernard  suggested  that  glycosuria  might 
be  cured  if  it  were  possible  to  galvanize  the  sympathetic  nerves.  The 
foregoing  experiments  demonstrate  that  glycosuria  may  be  caused  by 
a  variety  of  nerve  lesions  and  irritations. 

The  Circulation  and  Diabetes. —  The  occasional  occurrence  of  dia- 
betes in  connection  with  acute  inflammations  of  the  liver  and  passive 
hepatic  congestion  secondary  to  advanced  cardiac  disease  favors  the 
hypothesis  that  glycosuria  may  be  developed  by  an  increase  in  the 
amount  of  blood  flowing  through  the  liver,  which  is  hereby  stimu- 
lated to  an  active  conversion  of  its  glycogen  into  sugar,  or  else  the 
blood  passes  so  rapidly  through  the  liver  that  the  sugar  absorbed  from 
the  intestine  by  the  branches  of  the  portal  vein  does  not  have  time  to 
be  converted  into  glycogen,  but  passes  through  the  liver  into  the  gen- 
eral circulation  unaltered. 

Various  Theories  of  Diabetes. —  Huppert,  Pettenkofer,  and  Voit 
advocated  the  following  theory :  Glucose,  like  urea,  is  a  normal  prod- 
uct of  the  rapid  decomposition  of  albuminous  bodies.  In  health  this 
glucose  is  oxidized;  in  diabetes  less  oxygen  than  normal  is  absorbed, 
owing  to  the  destruction  of  the  red  blood-corpuscles  occasioned  by 
malnutrition ;  therefore  sugar  accumulates  in  the  blood. 

Lauder  Brunton  reported  several  cases  due  to  the  presence  of  a 
tapeworm.  He  thinks  that  the  increased  appetite  caused  by  the  pres- 
ence of  the  worm  may  have  been  instrumental  in  causing  the  gly- 
cosuria from  overeating,  but  it  is  possible  that  the  peripheral  irrita- 
tion of  sympathetic  nerve  fibers  may  have  been  conveyed  to  the  diabetic 
center  in  the  medulla,  and  thence  reflected  to  the  vasomotor  system  of 
the  liver,  or  the  worm  may  have  produced  a  toxin. 

Some  recent  experiments  and  clinical  observations  justify  the  belief 
that  the  skeletal  muscles  play  a  more  important  role  in  the  produc- 
tion of  diabetes  than  has  heretofore  been  supposed.  During  their 


DIABETES   1MELLITUS  735 

activity  they  normally  consume  glycogen  in  considerable  quantity. 
If  they  fail  to  perform  this  function  properly,  it  accumulates  in  the 
system. 

Kiilz  has  shown  that  muscular  activity  favors  the  consumption 
of  sugar  in  the  organism  of  the  diabetic,  and  that  much  less  sugar  is 
eliminated  while  such  patients  are  taking  vigorous  exercise. 

It  must  be  admitted  that  there  are  many  hepatic  diseases  and 
lesions  in  which  a  large  part  of  the  secreting  surface  of  the  organ  is 
destroyed,  and  in  which  glycosuria  never  may  be  present,  but  in 
these  conditions  it  is  possible  that  while  a  part  of  the  liver  is  totally 
destroyed  there  may  be  some  remaining  cells  which  are  endowed 
with  normal  functional  activity.  In  the  graver  forms  of  diabetes,  in 
addition  to  the  functional  disturbances  of  the  liver,  there  is  believed 
to  be  present  also  a  condition  of  malnutrition  in  which  sugar  either 
fails  to  be  consumed  or,  as  suggested  by  Yeo,  "we  may  suppose  that 
in  these  cases  a  morbid  ferment  is  formed  in  the  system,  possibly  in 
connection  with  some  radical  fault  of  stomach  or  intestinal  digestion, 
and  that  this  determines  the  rapid  reconversion  of  glycogen  into 
sugar/' 

Crofton  discovered  in  1901  that  injection  of  extract  of  the  adrenal 
bodies  into  animals  may  produce  glycosuria,  and  subsequently  C.  H. 
Herter,  experimenting  with  adrenal  extract  applied  to  the  pancreas 
surface,  gave  rise  to  glycosuria  in  the  dog.  Lepine  found  that  normal 
blood,  which  has  been  warmed  for  some  time  in  an  incubator,  con- 
sumes dextrose,  and  diabetic  blood  does  so  in  lesser  degree,  an  experi- 
ment which  suggests  that  one  factor  in  the  production  of  diabetes  may 
reside  in  the  blood  possibly  as  an  enzyme  derived  from  the  pancreas, 
absence  of  which  may  cause  glycosuria  (Carl  Ramus).  A  type  of 
renal  diabetes  is  developed  by  the  experimental  ingestion  of  phloridzin. 

From  all  the  experiments  thus  far  recorded  on  the  production 
of  glycosuria,  the  conclusion  is  inevitable  that  diabetes  may  be  the 
resultant  of  varied  conditions,  such  as  abnormal  functioning  of  the 
liver,  the  pancreas,  the  kidneys,  the  blood,  and  possibly  the  adrenals, 
and  thyroid,  to  which  may  be  added  functional  nervous  disturbances 
as  affecting  these  organs.  Whatever  the  origin  of  diabetes  in  differ- 
ent cases,  however,  the  disease  being  once  established,  the  dietetic 
influences  are  practically  the  same  for  all. 

Symptoms. —  The  most  important  symptoms  of  a  typical  case  of 
diabetes  which  are  to  be  combated  by  diet  are  (a)  extreme  thirst, 
(&)  hunger,  (c)  the  craving  for  sugars  and  starches,  (d)  the  large 
quantity  of  urine  voided  and  rapid  emaciation  and  loss  of  strength. 

(a)  Thirst.     The  Mouth. —  Thirst  becomes  excessive,  and  is  not 


736         DISEASES  ESPECIALLY  INFLUENCED   BY   DIET 

quenched  by  drinking,  although  patients  will  drink  almost  any  avail- 
able fluid  —  even  their  own  urine  —  in  their  endeavor  to  relieve  it. 

The  absorption  by  the  blood  vessels  of  fluid  from  the  tissues  is  held 
to  be  the  main  cause  of  this  thirst  (Vogel),  which  is  most  intense 
one  or  two  hours  after  meals,  when  sugar  formation  is  most  active, 
and  ten  or'  fifteen  quarts  of  water  may  be  consumed  daily  if  patients 
are  not  restrained  from  drinking  freely. 

The  saliva  is  thick,  frothy,  and  acid,  and  often  contains  sugar. 

The  mouth  becomes  sticky  or  dry,  even  to  the  extent  of  interfer- 
ing with  articulation,  and  there  is  often  a  sweetish  taste,  which  may 
be  accounted  for  by  the  sugar  present  in  the  saliva  and  the  blood  of 
the  capillaries  which  circulate  among  the  taste  bulbs. 

The  tongue  is  at  first  moist  and  sticky  and  coated  with  prominent 
papillae ;  later  it  may  become  dry,  dark  red,  and  fissured. 

( 6 )  Hunger. —  The  appetite  is  at  first  excessive ;  it  amounts  to 
bulimia  in  some  cases;  at  other  times  it  is  capricious  or  intermittent, 
and  subsequently  it  fails  completely  .when  the  digestion  becomes  im- 
paired through  the  symptoms  of  gastric  and  intestinal  catarrh. 

(c)  The  craving  for  sugars  and  starches  appears  as  a  special  symp- 
tom in  many  cases,  for  other  patients  temporarily  placed  upon  a  meat 
diet  for  other  diseases  do  not  manifest  it  in  like  degree. 

(d)  The  Urine. —  The  average  quantity  of  urine  voided  is  between 
two  to  three  times  the  normal  quantity  —  that  is,  from  3,000  to  4,500 
cubic  centimeters.     If  -water  is  being  drained  from  the  tissues  the 
quantity  of  urine  voided  may  exceed  the  amount  of  fluid  ingested, 
but  obviously  this  condition  cannot  last  very  long.     Exceptionally 
as  much  as  5,000  to  6,000  cubic  centimeters  or  more  may  be  voided 
within  twenty-four  hours. 

Frequent  calls  to  micturate  at  night  greatly  interfere  with  the  pa- 
tient's rest.  As  a  rule,  the  more  sugar  present  the  paler  is  the  urine, 
and  it  becomes  turbid  soon  after  standing,  from  the  development  of 
yeast  fungus  (Torula  cerevisia),  derived  from  the  atmosphere.  The 
sediment,  if  present,  is  usually  light,  and  the  odor  may  resemble  whey 
or  hay.  The  urine  is  sweetish ;  the  reaction  is  usually  acid,  but  may 
be  neutral  or  alkaline,  and  the  acidity  is  usually  proportionate  to 
the  quantity  of  sugar ;  it  is  increased  by  development  of  carbon  dioxide 
and  acetic  acid,  products  of  fermentation.  In  a  majority  of  cases  the 
specific  gravity  is  considerably  higher  than  the  normal,  rising  to  be- 
tween 1.030  and  1.050  or  more.  It  should  be  remembered  that  the 
quantity  of  urea  present  as  well  as  sugar  affects  the  specific  gravity, 
and  as  patients  are  usually  fed  upon  nitrogenous  food,  urea  is  natu- 
rally increased  beyond  the  normal  average. 


DIABETES  MELLITUS  737 

The  quantity  of  sugar  present  varies  greatly;  an  average  may  be 
stated  as  from  thirty-two  to  thirty-five  parts  per  thousand  of  urine, 
but  the  total  may  exceed  five  hundred  grams  (16^  ozs.)  per  diem. 

The  effect  of  a  heavy  meal  of  starchy  food  in  increasing  the  sugar 
is  promptly  shown  by  the  urine,  usually  within  two  hours,  and  it  lasts 
during  several  hours.  In  some  cases  very  little  sugar  is  eliminated, 
and  yet  the  symptoms  are  very  intense;  in  others  a  large  quantity  is 
voided  and  the  symptoms  are  not  at  all  severe,  but  as  a  rule  applying 
to  a  majority  of  cases,  the  severity  increases  or  diminishes  with  the 
quantity  of  sugar  voided.  After  grape  sugar  has  disappeared  during 
dietetic  treatment,  inosite  is  sometimes  found  in  the  urine,  as  in  sim- 
ple polyuria.  Other  substances  found  occasionally  in  connection  with 
sugar  are  acetone,  alcohol,  alkapton,  diacetic  acid,  aceton,  ,/J-oxy- 
butyric  acid,  peptones,  and  fat  (lipuria).  More  or  less  albuminuria 
is  observed. 

The  Skin  and  Bowels. —  Because  so  much  water  is  eliminated  in 
the  urine  there  is  scarcely  any  perspiration,  and  the  skin  becomes 
dry  and  wrinkled,  the  face  looks  drawn  and  pinched,  and  the  eyes  are 
hollow.  In  advanced  cases  a  sweetish,  sickening  odor  is  exhaled  from 
the  skin  and  in  the  expired  air.  From  lack  of  intestinal  secretion 
the  bowels  are  usually  constipated,  although  diarrhcea  may  alternate 
with  constipation. 

Later  Symptoms. —  In  the  later  stages  of  the  disease  dyspeptic 
symptoms  are  prominent  with  flatus,  sour  eructations,  and  a  disgust 
for  all  kinds  of  food.  The  teeth  decay,  the  gums  become  tender,  and 
mastication  is  difficult. 

The  loss  of  weight,  which  is  a  pronounced  feature  of  most  advanced 
cases  of  diabetes,  is  attributed  in  part  to  the  non-burning  of  carbo- 
hydrates, and  in  part  to  the  loss  of  their  proteid-protecting  action. 
In  health,  oxygen  is  used  to  consume  sugars,  which  in  diabetes,  when 
sugars  are  withheld,  burns  the  fat  of  the  body  instead,  so  that  the 
quantity  of  oxygen  inhaled  and  carbon  dioxide  exhaled  may  remain 
nearly  identical  in  the  two  conditions,  while  emaciation  progresses. 
In  addition  to  lack  of  nitrogen  of  the  tissues  the  wasting  is  also  in 
part  to  be  accounted  for  by  the  drain  of  fluid  from  the  system  which 
takes  place  when  once  polyuria  is  established.  Muscular  weakness 
and  debility  rapidly  supervene  to  a  greater  extent  than  is  to  be  ac- 
counted for  by  the  usual  loss  of  flesh. 

In  general,  it  may  be  said  in  the  milder  forms  of  diabetes  that  the 
sugar  in  the  urine  is  derived  from  carbohydrate  foods,  while  in  the 
more  serious  forms  it  is  derived  also  from  proteids.  The  sugar  which 

is  eaten  as  food  or  which  is  formed  by  starch  in  the  alimentary  canal, 
49 


738         DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

after  absorption  is  mainly  used  under  normal  conditions  in  the  pro- 
duction of  force,  but  in  diabetes  it  is  eliminated  unaltered  from  the 
body,  and  there  is  consequent  lack  of  heat  production  and  muscular 
power. 

Diabetic  coma  is  uniformly  fatal.  Many  theories  have  been  offered 
in  explanation  of  this  symptom,  and  one  is  that  it  is  produced  by  an 
acid  intoxication  produced  by  accumulation  in  the  system  of  /3-oxy- 
butyric  acid,  constituting  an  acidosis  (B.  Naunyn).  This  acid 
is  found  in  the  tissues  and  blood,  and  also,  in  combination  with  bases, 
in  the  urine.  It  is  not  present,  however,  in  all  cases.  It  is  derived 
from  tissue  albumins,  and  possibly  fats,  and  over  200  grams  may  be 
present  in  the  tissues  in  a  fatal  case.  Gangrene,  asthenia,  or  intercur- 
rent  diseases  cause  a  number  of  deaths. 

There  are  other  symptoms  affecting  the  nervous  system,  the  eyes, 
etc.,  and  there  are  many  complications  which  may  arise  in  the  course 
of  the  disease,  but  a  consideration  of  them  would  lead  too  far  from 
the  object  of  the  present  discussion,  which  is  to  deal  with  those  symp- 
toms which  bear  immediate  relation  to  metabolism  of  the  food. 

Some  of  the  complicating  diseases  with  which  diabetes  may  be 
associated  make  it  impossible  to  adhere  to  a  strict  regimen  without 
producing  more  harm  than  good.  Such,  for  example,  are  acute  gout 
and  chronic  nephritis,  in  both  of  which  an  excessive  diet  is  injurious, 
and  if  carbohydrates  are  also  cut  off  the  patient  has  little  or  nothing 
left  to  eat.  In  these  cases  the  diet  should  be  determined  by  whichever 
constitutes  the  graver  complication  (see  pp.  551,  721). 

The  course  of  diabetes  is  so  protracted  that  there  is  abundant  oppor- 
tunity for  trying  dietetic  experiments,  for  it  will  be  found  impossible 
to  establish  rules  for  dietetic  treatment  to  which  exceptions  may  not 
arise  from  time  to  time  in  any  individual  case. 

Prognosis. —  If  treatment  is  begun  before  the  symptoms  are  well 
advanced  the  lives  of  many  patients  may  be  prolonged  —  in  some  cases 
for  more  than  ten  or  twenty  years  —  but  between  50  and  60  per 
cent  of  all  cases  are  fatal  in  less  than  three  years;  undoubtedly 
a  few  which  are  recognized  sufficiently  early  may  be  cured  in  time, 
but  glycosuria,  like  albuminuria,  indicates  a  weakness  of  the  system 
in  a  special  direction,  and,  the  disease  having  once  occurred,  the 
patient  should  be  under  reasonable  supervision  for  many  years.  It 
has  been  aptly  said  that  "  the  only  chance  that  a  diabetic  has  of  being 
cured  is  to  believe  that  he  never  is  cured" — that  is,  to  be  constantly 
on  the  alert  to  avoid  all  indiscretions  in  hygienic  and  dietetic  mat- 
ters. Occasionally  diabetes  is  extremely  acute,  and  may  prove  fatal 
within  three  weeks,  but  in  such  instances  it  is  probable  that  glycosuria 


DIABETES   MELLITUS  739 

has  been  present  for  a  longer  time  without  discovery.  There  seems 
to  be  a  relation  between  the  general  bodily  nutrition  and  the  chance 
of  recovery  and  improvement.  Usually  stout,  middle-aged  men  yield 
best  to  treatment;  thin  persons  withstand  the  disease  less  well,  and 
rapid  emaciation  is  more  to  be  dreaded  than  the  mere  presence 
of  sugar.  When  a  mild  type  of  carbohydrate  diabetes  passes  into  the 
severer  proteid  type,  i.  e.,  when  sugar  is  formed  from  proteids  as  well 
as  carbohydrates,  there  is  usually  an  increase  of  nitrogen  elimination 
in  the  urine.  Hence  when  glucose  is  found  in  the  urine  of  a  patient 
who  has  been  taking  an  exclusive  proteid  diet,  a  fatal  termination  of 
the  disease  is  to  be  expected  very  soon.  The  prognosis  is  more  favora- 
ble if  the  sugar  does  not  speedily  return  if  the  dietetic  treatment  be  in- 
terrupted, and  also  if  the  amount  of  urea  excreted  is  large  and  the 
quantity  of  uric  acid  small.  Cases  associated  with  gout  are  relatively 
light.  In  emaciated  cases  the  malnutrition  is  so  great  that  the  pa- 
tients easily  acquire  other  diseases,  especially  pulmonar}^  tuberculosis, 
and  many  die  from  complications  rather  than  from  the  imme- 
diate effect  of  the  disease  itself.  In  youth  the  prognosis  is  always 
grave. 

Diagnosis. —  To  determine  the  presence  of  permanent  glycosuria, 
the  patient  should  be  'placed  for  two  days  upon  a  standard  diet  con- 
taining no  other  carbohydrate  food  than  100  grams  (S1/^  ozs.)  of 
wheat  bread  (von  Noorden).  The  urine  passed  during  twenty-four 
hours  is  then  collected  and  analyzed  by  polarization  and  titration  or 
fermentation.  If  sugar  be  present,  the  carbohydrate  allowance  should 
be  varied  for  a  day  or  two,  both  in  kind  and  quantity,  in  order  to  de- 
termine its  effect  upon  the  quantity  of  sugar  eliminated,  and  serve  as 
a  guide  for  dietetic  treatment.  By  this  test,  diabetics  may  be  grouped 
in  three  classes : 

(1)  Mild  cases  in  which  glycosuria  disappears  on  withdrawal  of 
carbohydrates  from  the  diet.  (2)  Medium  cases  in  which  glycosuria 
is  diminished  but  does  not  disappear  completely  upon  a  proteid  diet. 
(3)  Severe  cases  in  which  glycosuria  continues  unabated  upon  a  pro- 
teid diet. 

Temporary  glycosuria  may  be  caused  by  a  variety  of  conditions, 
such  as  excessive  indulgence  in  sweets,  poisoning  from  amyl  nitrite, 
mercury,  chloroform,  alcohol,  etc.  It  has  been  observed  during  preg- 
nancy, and  after  anthrax,  diphtheria,  scarlatina,  typhoid  fever,  etc. 
In  the  transient  form  of  glycosuria  the  urine  contains  much  less  sugar 
than  in  diabetes  mellitus,  and  all  the  grave  symptoms  of  excessive 
thirst,  emaciation,  and  extensive  tissue  waste,  leading  to  local  disease 
and  usually  death,  are  wanting. 


740 

In  polyuria  or  diabetes  insipidus  there  is  no  sugar  in  the  urine,  and 
the  specific  gravity  is  very  low  —  1.002  to  1.005. 

Primary  peptonuric  diabetes  or  peptonuria  is  described  by  Quin- 
quand  as  a  disease  presenting  the  clinical  features  of  mellituria  — 
thirst,  marked  cachexia,  polyuria,  etc. —  but  instead  of  sugar,  the 
urine  contains  peptones;  it  polarizes  to  the  left,  and  is  of  low  specific 
gravity, 

Temporary  lactosuria  sometimes  occurs  as  an  accompaniment  of 
the  puerperal  state,  and  is  not  of  special  dietetic  significance. 

Treatment 

The  treatment  should  be  (1)  prophylactic,  (2)  dietetic,  (3)  hy- 
gienic, and  (4)  medicinal. 

(1)    PROPHYLAXIS 

Until  more  is  known  of  the  aetiology  of  diabetes  definite  prophy- 
lactic rules  cannot  be  established;  but  in  general,  where  there  is  dis- 
tinct heredity  to  be  feared,  or  when  the  lithic-acid  diathesis  exists, 
all  excitement  of  the  nervous  system,  mental  or  physical,  as  well  as 
indulgence  in  alcohol  and  sweets,  should  be  avoided. 

(2)     DIETETIC    TREATMENT 

General  Observations. —  In  recent  years  the  dietetic  treatment  of 
diabetes  has  undergone  radical  changes.  Originally  the  diabetic  was 
placed  upon  an  almost  exclusive  proteid  diet,  with  the  minimum  of 
carbohydrates  contained  in  a  few  fresh  green  vegetables.  Subse- 
quently fats  were  added,  and  at  present  an  "isoglycosic  diet"  is  in 
vogue,  i.  e.,  a  diet  containing  carbohydrates  up  to  the  limit  of  tolera- 
tion of  the  system  for  them,  the  limit  at  which  they  may  not  produce 
an  excess  of  glucose  in  the  urine.  Finally,  it  is  recognized  that  in 
cases  in  which  glucose  is  derived  from  proteids,  a  liberal  mixed  diet 
presents  the  best  means  of  limiting  proteid  tissue  waste  and  conse- 
quent emaciation. 

The  rule  advocated  especially  by  von  Noorden,  and  now  generally 
accepted,  is  to  begin  treatment  by  testing  the  carbohydrate  toleration 
of  the  patient.  Carbohydrates  are  withheld  completely  for  a  few 
days,  and  then  given  and  slowly  increased  in  amount  until  sugar 
again  appears  in  the  urine,  when  the  limit  is  reached,  and  the  diet 
is  maintained  at  this  standard.  By  this  method  a  carbohydrate  tol- 
eration may  be  re-established  in  many  cases,  so  that  patients  who  pre- 
viously had  taken  carbohydrates  in  excess,  with  decided  glycosuria, 
may  continue  for  years  to  take  a  fixed  moderate  quantity  with  a 


DIABETES  MELLITUS 

minimum  glycosuria.  It  is  also  found  that  some  patients  tolerate 
one  or  another  form  of  carbohydrate  better  than  do  others.  Thus 
some  may  do  best  with  potatoes,  others  with  oatmeal,  others  with 
restricted  quantities  of  bread,  etc.  Periodically  (once  in  three  months 
is  my  personal  rule)  it  is  well  to  again  resort  to  an  exclusive  proteid 
diet,  for  two  or  three  weeks,  to  rid  the  system  of  any  excess  of 
glucose.  Upon  this  alternating  system  I  have  seen  very  favorable 
progress  in  cases  lasting  for  a  number  of  years.  As  soon  as  the 
urinalysis  shows  that  increasing  loss  of  weight  and  strength  is  due 
to  glucose  derivation  from  the  ingested  and  body  proteid,  dietetic 
rules  should  be  relaxed,  and  excepting  a  reasonable  restriction  as 
to  sugars,  the  patient  may  be  allowed  to  eat  what  he  chooses,  with 
the  result,  not  infrequently,  of  temporary  improvement  in  all  the 
symptoms.  As  an  intermediary  "  tissue  sparer "  and  "  force  pro- 
ducer/' the  fats  are  most  valuable,  as  they  do  not,  except  in  most 
advanced  cases,  augment  the  glycosuria.  They  should,  however,  be 
given  in  moderation  at  first,  and  occasionally  be  reduced  in  quantity, 
for  fatty  acids  are  the  forebears  of  acetone,  and  acetone  with  diacetic 
acid  and  beta-oxybutyric  acid  are  often  associated  with  diabetic  coma, 
although  it  is  not  yet  definitely  established  that  this  type  of  acidemia 
is  the  direct  cause  of  it.  The  Scylla  and  Charybdis  of  the  diabetic 
is  not  to  be  starved  to  death  for  lack  of  carbohydrates  on  the  one  hand, 
or  driven  to  acidemia  and  coma  from  excess  of  proteids  and  fats  on 
the  other.  The  danger  is  best  avoided,  therefore,  by  occasional  radi- 
cal changes  in  the  diet,  dictated  by  the  results  of  urinalysis,  the  pa- 
tient's weight,  strength,  and  other  symptoms. 

It  is  important  to  remember  the  influence  of  the  mental  and  nerv- 
ous system  upon  diabetes,  for  a  too  restricted  diet  may  produce  de- 
pressing effects  upon  appetite,  digestion  and  nutrition,  which  more 
than  counterbalance  the  risk  of  allowing  perhaps  another  potato  or 
slice  of  bread.  One  of  my  patients  with  unusual  fondness  for  the 
pleasures  of  the  table  actually  wept  over  the  prohibition  of  buckwheat 
cakes  and  maple  syrup.  When  allowed  this  unusual  clemency  twice 
a  week  he  promptly  gained  in  weight  and  strength,  and  showed  no 
serious  increase  in  glycosuria!  Such  a  case  is  not  cited  as  a  model, 
but  as  an  illustration  of  the  necessity  of  making  life  as  endurable 
as  possible  for  the  sorely  afflicted  diabetic,  whose  mind  is  unfor- 
tunately focused  upon  his  malady  three  times  a  day,  whenever  he  sits 
at  table. 

Phenomenal  improvement  follows  in  many  cases  upon  a  diet 
which  excludes  starches  and  sugars  completely,  but  this  is  a  diffi- 
cult regimen  to  enforce,  for  the  craving  for  carbohydrates,  especially 


742         DISEASES  ESPECIALLY   INFLUENCED   BY  DIET 

for  bread,  becomes  so  intense  that  patients  whose  veracity  is  other- 
wise unimpeachable  will  resort  to  any  form  of  deception  to  obtain 
the  coveted  food.  I  have  known  hospital  patients  to  steal  bread  and 
potatoes  and  consume  them  surreptitiously  in  spite  of  repeated  warn- 
ings, and  also  to  acquire  such  a  craving  for  fluid  as  induced  them  to 
drink  their  own  urine. 

It  is  a  matter  of  common  experience  that  the  most  difficult  of 
all  food  for  a  man  to  be  deprived  of,  when  once  accustomed  to  it,  is 
bread.  This  is  due  in  part  to  lifelong  association  of  certain  kinds  of 
food  with  one  another  at  meals  and  the  habit  of  eating  this  one  article 
of  food  with  more  constancy  than  any  other,  but  it  is  also  undoubtedly 
referable  to  a  positive  craving  of  the  system,  which  is  particularly 
marked  in  diabetes,  for  a  kind  of  food  which  the  tissues  need  but 
cannot  assimilate.  For  this  reason  it  is  advisable  often  to  allow 
patients  two  or  three  ounces  of  bread  a  day  in  divided  portions. 

While  it  is  necessary  to  secure  the  intelligent  co-operation  of  the 
patient  in  regard  to  carrying  out  his  treatment,  and  to  furnish  written 
directions,  it  is  highly  undesirable  that  he  should  devote  too  much 
time  and  attention  to  it,  and,  when  possible,  it  is  better  to  have  some 
one  else  select  and  provide  food  for  him  in  order  that  his  mind  may 
not  be  constantly  occupied  with  questions  of  dietetics  which  tend  to 
restrict  the  appetite. 

The  effect  of  no  dietetic  system  is  immediate,  and  several  days  may 
be  required  for  the  patient  to  come  fully  under  the  influence  of  treat- 
ment, because  the  materials  already  present  in  the  body  when  the  new 
diet  is  commenced  may  serve  as  a  source  of  sugar  for  some  little  time 
afterwards. 

For  convenience  of  description  of  dietetic  treatment  cases  of  dia- 
betes may  be  subdivided  into  three  classes:  (a)  Those  patients  who 
pass  a  considerable  quantity  of  urine  containing  a  large  percentage 
of  sugar,  but  in  whom  the  general  health  remains  good.  (&)  Cases 
in  which,  in  addition  to  the  passage  of  considerable  sugar  in  the 
urine,  there  is  more  or  less  dyspepsia,  emaciation,  and  debility,  (c) 
Cases  in  which  the  constitutional  symptoms  become  rapidly  serious 
after  the  first  appearance  of  sugar  in  the  urine. 

(a)  In  the  first  class  of  cases  the  dietetic  treatment  is  productive 
of  the  greatest  benefit,  and  not  rarely  the  patients  begin  to  gain 
flesh  and  strength ;  they  sleep  better ;  the  daily  quantity  of  urine  falls 
perhaps  from  three  hundred  ounces  to  seventy,  and  it  approaches 
the  normal  composition;  the  excessive  appetite  and  thirst  diminish; 
the  digestion  improves,  and  in  one  to  three  weeks  the  sugar  may 
entirely  disappear.  Such  patients  are  not  to  be  regarded  as  cured, 


DIABETES   MELLITTJS  743 

however,  as  soon  as  the  sugar  disappears  —  not,  in  fact,  until  they 
can  eat  starches  in  ordinary  quantity  without  exciting  the  appear- 
ance of  glycosuria.  According  to  the  statement  of  Dujardin- 
Beaumetz,  patients  of  this  class  may  be  cured  who  have  been  elimi- 
nating as  much,  as  six  ounces  of  sugar  per  diem. 

(&)  The  second  class  of  cases  is  also  amenable  to  dietetic  treat- 
ment, but  the  benefit  is  not  so  immediate  and  usually  not  so  great 
as  in  the  first  group,  and  it  may  be  impossible  to  cause  the  total  dis- 
appearance of  the  sugar,  although  it  may  be  reduced  to  two  or  three 
hundred  grains  a  day.  When  the  quantity  of  urine  is  lessened  by  the 
diet,  but  specific  gravity  remains  high,  and  sugar  is  abundant,  the 
prognosis  is  very  grave.  The  patient  cannot  tolerate  the  diet,  and 
drugs  may  be  resorted  to. 

(c)  In  the  third  and  very  critical  class  of  cases  dietetic  treat- 
ment is  much  less  successful,  but  it  should  be  undertaken,  for  it 
may  prevent  the  patient  from  becoming  worse,  although  it  is  unable 
to  accomplish  a  cure. 

By  different  writers  all  gradations  of  diet  have  been  recom- 
mended, so  long  as  the  carbohydrates  are  restricted,  from  the  ab- 
solute meat  diet  of  Cantani  and  the  skim-milk  diet  of  Donkin  to  the 
more  liberal  menu  of  the  majority  of  authorities. 

Some  patients  who  have  a  very  good  appetite  when  allowed  a 
mixed  diet  lose  it  altogether  when  put  upon  an  exclusive  nitroge- 
nous regimen.  There  are  those  who  can  live  contentedly  on  an  ex- 
clusive diet  of  proteid  food  and  fats  for  a  certain  length  of  time  — 
say  ten  days  or  a  fortnight  —  if  the  principle  of  the  treatment  be  ex- 
plained to  them  and  they  are  anxious  of  being  cured,  but  sooner  or 
later  they  almost  always  rebel,  and  may  prefer  to  live  less  long,  but  in 
more  comfort  than  such  restriction  implies.  This  is  probably  at- 
tributable more  to  long-continued  habit  or  heredity  than  actual  in- 
ability to  endure  life  of  this  sort,  for,  as  stated  elsewhere  (p.  359), 
the  Eskimos  and  other  tribes  of  man  thrive  upon  a  diet  absolutely  free 
from  starches  and  sugars  of  every  kind.  It  is  believed  by  Ebstein 
and  others  that  an  exclusive  meat  diet  may  be  injurious  on  account 
of  a  tendency  to  produce  acetonaemia,  and  may  favor  the  increase  of 
uric-acid  deposits  in  those  having  the  uric-acid  diathesis.  It  de- 
velops pruritus  (p.  560),  and  may  irritate  the  kidneys. 

When  chronic  nephritis  complicates  diabetes  the  difficulty  of 
dieting  is  much  enhanced,  for  meat  is  injurious  for  the  nephritis, 
as  starches  are  in  diabetes.  As  a  compromise  such  patients  may  be 
given  a  milk  diet  for  a  few  weeks  at  a  time. 

In  patients  over  50  years  of  age,  whose  general  health  remains 


744         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

fairly  good,  I  am  accustomed  to  alternate  periods  of  restriction  and 
relaxation  in  dieting,  depending  upon  the  condition  of  the  urine  and 
other  symptoms.  In  a  disease  which  lasts  for  years  it"  is  so  great  a 
relief  to  be  released  occasionally  from  routine  that  the  moral  effect 
often  benefits  the  patient,  and  he  may  temporarily  gain  in  weight  and 
strength.  If,  for  example,  the  sugar  in  the  urine  remains  at  0.5  of  one 
per  cent  or  less,  and  the  specific  gravity  below  thirty,  it  may  be  safe 
to  allow  temporarily  a  lump  or  two  of  sugar,  a  slice  of  toast,  a  griddle 
cake,  or  some  other  form  of  sweets  which  the  patient  may  particularly 
crave.  I  have  patients  who  have  been  under  observation  for  six  or 
eight  years  who  have  been  none  the  worse  for  such  latitude. 

Many  elaborate  diet  tables  have  been  prepared,  and  for  those 
whose  means  permit  of  indulgence  in  delicacies  considerable  variety 
may  be  secured  without  the  use  of  carbohydrates;  but  for  the  poor 
in  hospitals  and  at  home  it  is  a  difficult  problem  to  furnish  inexpen- 
sive variety  without  occasional  recourse  to  starchy  foods. 

Foods  Allowed  in  Diabetes 

Soups  and  broths  made  of  meat  of  any  kind  without  vegetables, 
ox-tail  and  turtle  soup,  gumbo,  curry. 

Eggs  in  any  form. 

Crustaceans,  crabs,  lobsters,  shrimp.     Terrapin. 

Fresh  fish  of  all  kinds  and  fish  roe.  Caviare,  anchovies.  Salt 
fish,  cod,  mackerel,  and  herring  may  be  allowed,  unless  they  increase 
thirst  too  much. 

Fresh  meat,  fowl  and  game  of  all  kinds.  Ham,  bacon,  smoked 
beef,  tongue,  sweetbreads,  kidneys,  tripe,  calf's  brains. 

Fats. —  Olive  oil  and  all  animal  fats  and  oils,  such  as  butter  (in 
moderation),  cream,  cod-liver  oil,  bone  marrow.  In  some  diabetic 
patients  the  power  of  fat  digestion  is  apparently  increased,  so  that 
they  tolerate  larger  quantities  than  in  health. 

Vegetables. —  Spinach,  cress,  sorrel,  chicory,  romaine,  dandelions, 
beet-tops,  horse-radish,  radishes,  celery,  sea-kale,  artichokes,  vege- 
table marrow,  okra,  lettuce,  endives,  pickles,  cucumbers,  gherkins, 
cranberries.  The  following  vegetables  are  allowed  by  some  writers, 
prohibited  by  others :  green  French  string  beans,  asparagus,  summer 
squash,  onions,  leeks,  carrots,  cauliflower,  cabbage,  sauerkraut,  kohl- 
rabi, parsley,  parsnips,  eggplant,  tomatoes,  rhubarb. 

Because  potatoes  contain  about  one-fifth  as  much  starch  as  that 
present  in  bread  they  may  be  allowed  in  moderation  when  the  latter  is 
found  to  disagree.  (Fig.  45,  p.  745). 

The  following  statement  made  by  Fagge  is  useful :     "  The  general 


DIABETES   MELLITUS 


745 


rule  is  that  all  white  parts  of  vegetables  in  which  chlorophyll  has  not 
been  developed  by  exposure  to  sunlight  contain  no  sugar,  and  are 
not  harmful.  But  by  boiling  in  a  large  quantity  of  water,  even  the 
forbidden  kinds  of  vegetables,  if  they  contain  sugar  only  and  not 
starch,  may  be  rendered  much  less  injurious."  There  is  a  decided 
advantage  in  using  such  green  vegetables  as  are  allowed  in  diabetic 
diet  on  account  of  their  adding  to  the  bulk  of  waste  matter  in  the 
intestine  and  preventing  constipation,  which  almost  inevitably  re- 
sults from  a  meat  diet. 

Truffles,  mushrooms. 

Milk,  cheese,  cream,  milk  curds,  buttermilk,  Koumyss. 

Jellies  made  of  calf's  foot  gelatin  with  wine,  but  unsweetened 
except  with  saccharin,  coffee  jelly,  lemon  jelly. 

Fruits,  if  acid,  not  sweet.  In  England,  where  gooseberries  are 
eaten  much  more  than  in  this  country,  they,  as  well  as  apples,  red 
currants,  and  sour  cherries,  are  sometimes  allowed.  Many  of  these 

FIG.  45. 


BREAD. 

POTATO 

OATMEAI 


DIAGRAM  OF  THE  RELATIVE  PROPORTION  OF 


CARBOHYDRATE  IN   FOODS  ALLOWED  DIABETICS 


FAT 


fruits  contain  more  levulose  than  grape  sugar.  Sour  oranges, 
lemons,  grape  fruit,  pineapple  juice,  olives,  sour  apples,  peaches  in 
brandy  (without  sugar),  raspberries,  and  strawberries  are  allowed  by 
some,  but  are  usually  forbidden.  Muskmelons  and  watermelons  may 
be  eaten. 

Nuts. —  Oily  nuts,  such  'as  almonds,  walnuts,  Brazil  nuts,  hazel- 
nuts,  filberts,  pecan  nuts,  butternuts,  cocoanuts,  beechnuts. 

The  articles  above  enumerated  afford  considerable  choice,  and  it 
is  to  be  distinctly  understood  that  only  so  many  of  them  are  to  be 
allowed  at  a  time  as  may  serve  to  divert  the  craving  of  the  patient 
from  his  chief  enemy  —  concentrated  carbohydrates.  Some  patients 
will  be  found  who  can  eat  any  of  the  above  articles  with  impunity, 
while  others  can  take  very  few,  and  others  may  consume  certain  foods 
for  a  short  time  without  increasing  their  sugar  elimination,  which 
suddenly  will  be  found  to  agree  no  longer,  when  some  other  food  may 

be  substituted. 
50 


DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

A  Useful  Diabetic  Diet  in  Detail 

I  recommend  the  following  dietary   (alternatives  in  brackets)   in 
average  cases : 

Breakfast,  8  A.  M. —  A  sour  orange  [grape  fruit,  melon] ;  eggs, 
scrambled,  with  much  butter;  fresh  mackerel  [salmon  or  other  fat 
fish]  ;  two  slices  buttered  toast,  three  inches  square,  one-third  inch 
thick  =  about  one  ounce ;  coffee,  with  cream  and  saccharin. 

II  A.  M. —  A  glass  of  cream  diluted  with  water  or  Vichy  to  the 
consistency  of  milk  [a  glass  of  eggnog  with  saccharin] . 

Luncheon,  1  p.  M. —  Bacon  and  eggs  [sardines]  ;  spinach  [rad- 
ishes, celery],  olives,  lettuce,  with  oil  dressing,  and  cheese;  nuts. 

Tea,  5  p.  M. —  A  cup  of  tea  with  cream  and  saccharin;  a  baked 
apple  with  eream;  a  slice  of  buttered  toast  (as  at  breakfast). 

Dinner,  8  P.  M. —  Meat  soup ;  fresh  fish  with  butter  sauce ;  cucum- 
bers with  oil;  entree,  marrow  bones;  meat  (any  sort);  a  baked 
potato  (three  inches  long),  well  mashed,  with  much  butter;  string 
beans  [cauliflower,  vegetable  marrow,  Brussels  sprouts,  onions, 
asparagus  with  butter  sauce];  (fat  corn-beef  and  cabbage  or  pork 
and  sauerkraut  may  be  allowed  once  a  week) ;  game;  sliced  tomatoes 
with  oil;  baked  custard  [blancmange  made  with  diabetic  milk  and 
saccharin;  fruit  jelly  made  with  gelatin  and  imbedded  fruits,  such 
as  oranges,  cherries  or  currants,  unsweetened] ;  black  coffee ;  very  dry 
Moselle  or  dry  champagne. 

This  dietary  should  be  varied  from  time  to  time.  As  the  tol- 
erance for  carbohydrates  increases  the  fats  may  be  reduced,  and 
vice  versa. 

If  after  a  brief  test  of  animal  food  exclusively  the  glucose  in 
the  urine  remains  above  0.5  of  one  per  cent,  and  glycosuria  and 
weight  rapidly  diminish,  meats  should  be  replaced  to  the  extent  of  not 
more  than  one-half  by  carbohydrates  and  fresh  fruits  and  vegetables. 
It  will  be  noticed  that  both  toasted  bread  and  potatoes  enter  into  the 
above  dietary.  If,  with  a  test  diet  of  carbohydrate-free  food,  to  which 
100  grams  (S1/^  ozs.)  of  bread  is  added,  no  excess  of  glucose  is  ex- 
creted, but  it  is  excreted  with  200  grams  (6%  ozs.)  of  bread  added, 
then  a  moderate  toleration  for  bread  is  demonstrated,  and  it  may  be 
given  up  to  this  limit  of,  say  100  grams  (3%  ozs.)  per  diem.  A 
similar  test  may  be  applied  to  potatoes. 

In  the  poor  man's  anti-diabetic  dietary,  pork,  bacon,  tripe,  cab- 
bage, sauerkraut,  carrots,  turnips,  onions,  leeks,  and  milk  cheese 
may  form  the  basis  of  the  heavier  meals.  Lard,  suet,  and  margarine 
should  be  used  freely  in  the  cooking. 


DIABETES   MELLITUS  ?47 

Forbidden  Foods 

Sugar  in  any  form  —  sirup,  molasses,  confectionery,  jams,  and 
sweets  of  all  kinds ;  honey,  for  it  contains  dextrose  and  levulose. 

Starches. —  All  the  elementary  forms  of  starchy  and  farinaceous 
food,  such  as  rice,  sago,  tapioca,  arrowroot,  oatmeal,  cornmeal,  hom- 
iny, samp,  buckwheat,  barley,  semolina,  macaroni,  spaghetti,  vermi- 
celli. All  pastry,  cake,  preserves,  confectionery,  sweet  sauces,  pud- 
dings, pies  of  every  description  —  in  short,  everything  made  of  flour 
excepting  a  little  bread  as  specified  above. 

Vegetables. —  Sweet  potatoes,  beets,  carrots,  parsnips,  turnips,  peas, 
corn,  beans  of  all  kinds  (except  string  beans),  lentils,  cauliflower, 
broccoli,  Brussels  sprouts.  Some  writers,  like  Dujardin-Beau- 
metz,  occasionally  allow  a  well-baked  white  potato  in  mild  cases. 
It  contains  only  15^  per  cent  of  starch,  or  one-fifth  as  much  as  rice, 
and  one-half  as  much  as  peas  and  beans.  I  frequently  prescribe  it  in 
lieu  of  bread. 

Shellfish. —  The  soft  parts  or  livers  of  clams,  oysters,  and  mussels 
contain  glycogen.  By  some  these  foods  are  entirely  forbidden,  but 
many  diabetic  patients  may  take  them  occasionally  without  injury. 

Liver  of  all  other  animals  (it  contains  glycogen),  pate  de  foie  gras. 

Fruits. —  In  regard  to  the  use  of  fruits  there  is  some  difference  of 
opinion,  as  stated  on  page  745.  Sweet  fruits,  such  as  figs,  dates, 
plums,  prunes,  bananas,  apricots,  all  preserved,  candied,  or  sugared 
fruits  must  be  absolutely  interdicted.  Apricots,  peaches,  nectarines, 
plums,  pears,  melons,  and  berries  are  forbidden  by  many,  but  allowed 
by  others. 

Nuts. —  Chestnuts,  cocoanuts.  Peanuts  are  not  nuts  at  all,  but 
contain  much  starch,  and  are  therefore  forbidden. 

Substitutes  for  Bread 

The  problem  of  selecting  a  suitable  starchy  food  for  the  diabetic 
is  governed  by  the  necessity  of  furnishing  it  in  some  form  which  will 
satisfy  the  craving  for  farinaceous  material  and  not  seriously  impair 
nutrition. 

The  most  difficult  of  all  starchy  food  for  the  patient  to  forego  is 
bread.  Much  ingenuity  has  been  expended  in  attempts  to  devise  sub- 
stitutes for  it,  and  many  preparations  for  making  artificial  breads, 
biscuits,  rusk,  or  cakes  with  eggs  and  butter  are  sold  in  market  for 
this  purpose.  Some  of  these  are  palatable  for  a  time,  but  many 
have  been  found  to  contain  60  or  80  per  cent  of  starch  —  fully  as 
much  as  wheaten  bread  —  while  others  contain  no  nutriment  at  all. 


748          DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

Some  authorities,  as  Germain  See  and  Dujardin-Beaumetz,  advise 
using  potato  meal  instead  of  bread,  five  ounces  per  diem,  which 
may  be  cooked  in  any  form  without  sugar.  Mosse  is  alone  in  the  be- 
lief that  the  potassium  salts  of  the  potato  possess  special  curative 
value.  Sawyer  suggests  the  use  of  potato  flour  in  bread,  cake,  etc., 
for  diabetics,  and  gives  the  following  prescription : 

Bran  and  potato  bread.  Take  half  a  pound  of  flour  of  steamed 
potatoes,  quarter  of  a  pound  of  bran,  half  an  ounce  of  German 
yeast,  half  an  ounce  of  butter,  one  egg.  Twenty-four  hours  before 
making  the  dough  cook  the  potatoes  by  steaming  them  in  their 
jackets,  then  peel  and  break  up  into  flour  with  the  fingers.  Mix 
all  the  ingredients  together,  and  let  the  paste  stand  near  the  fire  for 
an  hour  to  rise.  Bake  in  greased  tins  for  an  hour  and  a  half. 

The  breads  made  from  flour  especially  prepared  for  diabetics  are: 
(a)  Gluten  bread;  (&)  bran  bread;  (c)  almond  bread;  (d)  inulin 
bread;  (e)  soya  bread. 

(a)  Gluten  Bread. —  Gluten  bread  was  first  used  by  Bouchardat. 
It  is  made  by  washing  wheat  flour  in  such  a  manner  as  to  remove 
the  starchy  granules,  leaving  the  gluten  behind.  Such  bread  is  cer- 
tain to  contain  more  or  less  starch,  and  not  seldom  it  has  both  starch 
and  sugar.  It  is  usually  soon  tired  of,  and  unless  prepared  by  a  very 
reliable  manufacturer  it  has  little  to  recommend  it.  It  is  not  agree- 
able to  masticate,  for  it  is  often  unpleasantly  tough  and  stringy.  It 
is  difficult  to  panify,  but  may  be  aerated.  Gluten  biscuits  are  more 
palatable  than  gluten  bread,  but  most  of  these  preparations  have  the 
disadvantage  of  not  keeping  fresh  for  more  than  a  week  or  ten  days. 

Gluten  flour  is  used  for  thickening  broths,  egg  puddings,  etc. 

Following  are  two  receipts  for  utilizing  gluten  flour : 

Jeffrie's  Gluten  Biscuit  for  Diabetics. 

Gluten    flour     1  cup. 

Best    bran,   previously   scalded    1  cup. 

Baking  powder    (or  the  equivalent  of  bicarbonate  of 

soda  and  cream  of  tartar)    1  teaspoonful. 

Salt     to  taste. 

Eggs     2. 

Milk  or   water    1  cup. 

Mix   thoroughly. 

James  Stewart's  Diabetic  Bread. —  "Take  one  quart  of  sweet  milk 
or  milk  and  water,  one  heaping  teaspoonful  of  good  butter,  one-fifth 
of  a  cake  of  compressed  yeast  beaten  up  with  a  little  water,  and  two 
eggs  well  beaten.  Stir  in  gluten  flour  until  a  soft  dough  is  formed, 
knead  as  in  making  ordinary  bread,  put  in  pans  to  raise,  and  when 
light  bake  in  a  hot  oven." 


DIABETES   MELLITUS  749 

Van  Abbott  recommends  the  use  of  gluten  macaroni,  gluten  ver- 
micelli, and  gluten  semolina,  which  may  be  made  into  puddings  with- 
out sugar. 

Liebig  proposed  to  prepare  bread  for  diabetics  by  pouring  a  malt 
infusion  over  thinly  sliced  wheaten  bread.  The  sugar  which  is  thus 
formed  is  washed  away,  and  the  gluten  residue  may  be  eaten. 

It  is  very  difficult  to  obtain  a  reliable  gluten  flour.  Much  that 
is  sold  in  open  market  contains  more  starch  than  wheaten  bread  —  it 
may  hold  60  or  75  per  cent.  It  may  also  contain  sugar. 

The  gluten  flour  obtained  in  market  in  London  or  Paris  contains 
about  15  per  cent  of  starch,  whereas  that  sold  in  the  United  States 
frequently  has  two  or  three  times  as  much. 

In  1903  the  New  Hampshire  State  Board  of  Health  reported  that 
of  thirteen  samples  of  "  diabetic  "  and  "  gluten  "  flours,  seven  con- 
tained nearly  the  average  starch  percentage  of  ordinary  wheaten 
flour,  and  only  two  were  almost  free  from  it. 

James  Stewart  gave  the  following  test  for  starch  to  be  applied 
to  gluten  flour:  A  little  of  the  flour  is  shaken  well  with  boiling 
water,  and  cooled.  A  few  drops  are  then  added  of  an  aqueous  solu- 
tion of  iodine  and  potassium  iodide  (Gram's  solution).  If  starch 
be  present,  a  decided  blue  color  develops. 

Dujardin-Beaumetz  declared  that  gluten  bread  contains  more  than 
three  times  as  much  sugar-forming  material  as  potatoes,  and  hence 
he  prescribed  the  latter  instead. 

A  serious  objection  to  the  use  of  gluten  flour  and  gluten  biscuits, 
etc.,  is  that  patients  often  buy  these  articles  for  themselves  and,  be- 
lieving that  they  are  free  from  starch  and  sugar,  eat  all  they  desire, 
whereas,  if  ordinary  toasted  bread  or  potatoes  be  prescribed  in  limited 
quantity,  the  physician  may  know  exactly  how  much  carbohydrate  is 
being  consumed  —  with  gluten  he  is  uncertain,  and  I  have  long  ceased 
to  recommend  it. 

Most  gluten  bread  keeps  fresh  only  a  few  days.  An  exception  to 
this  statement  is  found  in  a  bread  made  by  0.  Eademann,  of  Frank- 
fort a.  M.,  which,  according  to  von  Xoorden,  contains  only  25  per 
cent  carbohydrates. 

Tyson  of  Philadelphia  says :  "  One  of  the  best  English  houses,  Cal- 
lard,  Stewart  &  Watt,  65  Eegent  St.,  London,  has  opened  an  agency  in 
New  York  City,  whence  may  be  obtained  a  variety  of  pure  gluten 
foods.  They  are  called  casoid  diabetic  foods.  I  add  a  list  of  some  of 
them: 

Casoid  flour  for  making  starchless  and  sugarless  bread,  cakes,  bis- 
cuits, pastry,  etc.  Said  to  keep  indefinitely. 


750         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

Casoid  biscuits  No.  1  (plain).  Suitable  for  use  instead  of  bread 
at  all  meals.  Excellent  with  cheese.  Said  to  keep  in  good  condition 
indefinitely  if  stored  in  a  cool  place. 

Casoid  biscuits  No.  2.  Plain  biscuits  for  general  use  instead  of 
bread.  Should  be  stored  in  a  cool  place. 

Casoid  biscuits  No.  3.  Sweetened  with  saccharin.  For  use  at 
breakfast  and  tea. 

Casoid  sugarless  chocolate.  In  small  tablets,  slightly  sweetened, 
consisting  of  pure  concentrated  chocolate.  One  tablet  dissolved  in 
hot  water  makes  a  cup  of  chocolate. 

The  flour  and  biscuits  I  have  tested  and  found  starch  and  sugar 
free." 

These  foods  are  also  recommended  by  von  Noorden,  and  A.  L. 
Winton  of  the  Connecticut  Agricultural  Experiment  Station  found 
Casoid  Four  entirely  free  from  carbohydrates,  but  the  biscuits  con- 
tained 8.07  per  cent. 

Protene  Diabetic  Bread,  made  in  England  by  the  Protene  Com- 
pany, has  its  basis  in  casein,  and  is  said  by  Eobert  Hutchison  to  be 
"  entirely  free  from  carbohydrate."  It  may  be  toasted  with  advantage 
to  taste. 

Fromentine  is  another  form  of  diabetic  flour  made  from  wheat 
germs.  They  contain  less  starch  than  mature  wheat,  but  hold  an  oil 
which  is  purgative  and  which  prevents  proper  panification,  and  causes 
the  bread  to  sour  easily. 

Polubos'kos  is  another  form  of  flour  said  to  contain  a  minimum 
of  starch. 

Embryonine  or  legumine  is  a  substance  isolated  from  the  casein 
of  legumes,  and  which  is  sometimes  given  in  diabetes. 

(&)  Bran  Bread. —  The  use  of  bran  bread  was  first  suggested  by 
Prout,  but,  like  gluten  bread,  it  is  liable  to  contain  starch,  and  in 
addition  tough  cellulose,  which  is  of  little  nutrient  value  and  which 
may  prove  irritating  to  the  mucous  membrane  and  alimentary  canal, 
causing  diarrhoea.  It  is,  moreover,  somewhat  tasteless,  and  patients 
quickly  tire  of  it.  Bran  bread  cakes  may  be  purchased  prepared 
expressly  for  the  use  of  diabetics.  They  are  made  according  to  Dr. 
Camplin's  receipt,  as  follows : 

Cam  pirn's  Bran  Bread. —  "Boil  one  quart  of  wheat  bran  in  two 
successive  waters,  wash  in  a  sieve  with  hot  water  until  the  water 
runs  through  clear.  Squeeze  in  a  cloth  after  each  washing.  Spread 
thinly  on  a  dish,  and  dry  in  a  slow  oven.  Grind  in  a  fine  mill,  and 
sift  by  brushing  through  a  very  fine  sieve.  Grind  the  residue  again 
and  sift.  Take  of  the  powder  three  ounces,  three  new  laid  eggs, 


DIABETES   MELLITUS  751 

butter  two  ounces,  and  half  a  pint  of  milk.  Mix  the  eggs  with  a 
little  of  the  milk,  warm  the  butter  with  the  rest.  Stir  the  whole  and 
flavor  with  nutmeg  or  ginger.  Bake  in  thin  cakes  in  a  quick  oven 
for  half  an  hour."  More  eggs  may  be  used,  and  Roberts  adds 
sodium  bicarbonate.  The  object  of  drying  the  bran  before  it  is 
ground  is  to  make  it  friable,  otherwise  it  is  too  soft  to  be  easily 
powdered.  These  cakes  or  biscuits  may  be  eaten  with  butter  or 
cheese,  and  taken  with  meals  two  or  three  times  a  day. 

(c)  Almond  Calces. —  Pavy  first  suggested  the  use  of  almond  cakes 
for  diabetics,  which  he  prepared  by  making  a  meal  of  sweet  almonds. 
This  meal  when  washed  in  acidulated  water  is  freed  from  sugar,  and 
may  be  made  into  cakes  or  crackers.  Seegen  gives  the  following 
receipt  for  almond  cakes: 

Seegen's  Almond-flour  Calces. —  "  Take  of  blanched  sweet  almonds 
a  quarter  of  a  pound,  reduce  to  powder  in  a  stone  mortar,  steep  in 
linen  in  boiling  water,  acidulated  with  vinegar,  for  fifteen  minutes 
to  remove  sugar.  Mix  the  paste  with  three  ounces  of  butter  and 
two  eggs,  add  the  yolks  of  three  eggs,  a  pinch  of  salt,  stir  well. 
Whip  the  whites  of  three  eggs  and  stir  in.  Put  the  dough  into 
greased  molds,  dry  at  a  slow  fire."  Almond-flour  preparations  con- 
tain so  much  fat  that  they  often  prove  indigestible  after  a  few  days' 
trial,  and  they  are  relatively  expensive.  Macaroons,  if  unsweetened, 
may  be  used. 

Many  physicians  prefer  to  discard  the  use  of  all  substitutes  for 
bread,  such  as  bran  and  almond  cakes,  and  to  allow  the  patients  a 
limited  amount  of  plain  bread. 

A  nut  flour,  the  Chicago  Sanitary  Flour,  is  recommended  by  N".  S. 
Davis,  Jr.,  of  Chicago.  Analysis  by  Prof.  J.  H.  Long  shows  it  to 
contain : 

Water     8.01 

Fat    19.82 

Albuminoids    55.65 

Sugar    6.25 

Mineral  salts    6.32 

Fibre  and  other  non-nitrogenous  matter   3.95 


100.00 

It  is  thus  seen  to  contain  no  starch,  and  most  of  the  6.25  per 
cent  of  sugar  is  said  to  be  lost  by  conversion  to  CO,  in  the  fermenta- 
tion process  of  breadmaking.  It  is  alleged  to  be  useful  not  only  for 
diabetics  but  for  those  having  flatulent  dyspepsia. 

( d)  Inulin  Bread. —  A  form  of  bread  has  been  made  by  Kiilz 
from  inulin  and  lichinin.  Inulin  is  derived  from  the  root  of  elacam- 
pane  (Inula  lielenium). 


752         DISEASES   ESPECIALLY   INFLUENCED   BY   DIET 

Kiilz's  Inulin  Biscuits. —  "  Fifty  grams  of  inulin  are  to  be  put  in 
a  large  porcelain  basin,  and  while  standing  over  a  water  bath  to  be 
rubbed  up  with  thirty  cubic  centimeters  of  milk,  and  as  much  hot 
water  as  may  be  necessary,  into  a  uniform  dough,  with  which  the 
yolks  of  four  eggs  and  a  little  salt  are  to  be  mixed.  To  this  the 
whites  of  four  eggs  are  to  be  added,  having  first  beaten  them  to  a 
foam  and  carefully  worked  them  in.  The  dough  is  finally  to  be  baked 
in  tin  molds,  previously  smeared  with  butter.  The  taste  of  the 
biscuits  may  be  improved  by  the  addition  of  vanilla  or  spices." 
(Dietary  of  the  Sick.  Yon  Ziemssen's  Handbook  of  General  Thera- 
peutics.) These  biscuits  are  not  agreeable  to  the  taste  and  patients 
soon  tire  of  them. 

(e)  Soya  Bread. —  A  meal  is  made  from  the  fruit  of  the  Soya 
hispida,  a  bean  which  is  grown  in  China  and  Japan  and  also  raised 
in  Austria.  It  is  very  rich  in  protein.  It  has  a  peculiar  flavor  and 
holds  a  purgative  oil. 

The  published  percentage  composition  of  the  more  important  in- 
gredients of  soya  bread  is  as  follows: 

Water     45.000 

Protein     20.168 

Fats    9.350 

Starch  and  sugar    2.794 

Phosphoric    acid 0.863 

Soya  bread'  is  nutritious  on  account  of  the  large  percentage  of 
fat  which  it  contains,  but  according  to  an  analysis  made  by  an  expert 
chemist  it  contains  carbohydrates  in  considerable  amount.  This, 
in  fact,  is  true  of  all  the  breads  and  biscuits  made  of  substitutes  for 
flour. 

Cocoa  and  chocolate  in  special  preparations  are  recommended  by 
von  Xoorden.  Such  are:  a  saccharin  chocolate  made  by  Hcevel  of 
Berlin,  Germany,  and  a  saccharin  "  cocoa  for  diabetics  "  made  by  0. 
Rademann  of  Frankfort  a.  M.,  Germany,  each  containing  12  per  cent 
carbohydrates.  The  dose  is  5  ounces. 

Stollwerk's  levulose  chocolate  contains  50  per  cent  of  levulose  and 
5.6  per  cent  of  other  carbohydrates. 

Von  Xoorden  gives  a  useful  quantitative  summary  as  a  guide  for 
feeding:  3  grams  (46  grains)  of  carbohydrates  are  contained  in  each 
of  the  following  measures: 

One  tablespoonful  of  mashed  potato. 

Two  tablespoonfuls  of  green  vegetables. 

Eight  almonds,  six  English  walnuts,  t.en  hazelnuts. 

Two  tablespoonfuls  of  berries. 


DIABETES   MELLITUS  753 

Substitutes  for  Sugar 

Kiilz  states  that  certain  of  the  sugars  and  allied  bodies  may  be 
used  with  the  food  without  increasing  the  glycosuria,  being  very 
thoroughly  consumed  within  the  body.  Such,  for  instance,  are  inu- 
lin,  inosite,  mannite,  and  levulose  or  sugar  derived  from  fruits.  A 
preparation  of  the  latter  is  sold  under  the  name  of  "  diabetin."  An- 
other sugar  substitute  known  as  "crystalose"  is  much  prescribed  at 
Carlsbad,  and  extensively  used  in  this  country. 

Glycerin  has  also  been  used,  but  Senator  and  Frerichs  are  op- 
posed to  it.  If  given  in  quantity,  such  as  one  or  two  ounces  a  day, 
it  occasions  intestinal  disorder,  and  may  prove  too  laxative.  It  also 
causes  a  continuous  sweet  taste  in  the  mouth. 

Saccharin  is  employed  with  success  to  take  the  place  of  cane 
sugar  for  sweetening  foods  for  diabetic  patients.  It  may  be  used 
to  sweeten  coffee  and  other  materials.  It  is  a  crystalline  nitrog- 
enous body  derived  from  coal  tar,  which  is  sparingly  soluble  in 
cold  water,  more  soluble  in  hot  water,  and  very  soluble  in  glycerin. 
It  is  about  three  hundred  times  as  sweet  as  cane  sugar,  and  when 
taken  not  to  exceed  four  or  five  grains  daily  it  is  quite  harmless. 
Eaten  in  large  quantity  it  disorders  digestion  and  causes  gastric 
pain. 

A  convenient  formula  was  given  by  James  Stewart  for  saccharin 
pastilles  as  follows: 

Saccharin    gr.  xlv. 

Sod.  bicarb,   sice 3  ss. 

Manniti      3  xijss. 

M.     Make  100  pastilles;  one  will  sweeten  a  cup  of  tea  or  coffee. 

Cooking 

Care  should  be  exercised  in  the  preparation  and  cooking  of  the 
food  for  diabetic  patients  that  injurious  ingredients  are  not  added 
for  the  purpose  of  flavoring  or  thickening.  For  this  reason  all  ar- 
ticles of  diet  should  be  cooked  as  simply  as  possible,  and  rich  sauces 
containing  flour  are  forbidden.  Melted  butter  may  be  used  as  a  sub- 
stitute. Eoast  beef  should  not  be  basted  with  flour,  and  meat  soups 
should  not  be  thickened.  Vegetables  which  have  been  boiled  for  a 
long  time  in  a  large  bulk  of  water  have  most  of  their  sugar  dissolved 
out,  and  on  that  account  are  less  injurious. 

Very  acid  fruits  may  be  sweetened  with  saccharin  or  cooked  with 
a  little  sodium  or  potassium  bicarbonate  to  neutralize  their  acidity. 
The  latter,  process  does  not  impair  their  flavor. 


754         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

Beverages 

Water. —  It  is  an  important  matter  to  decide  to  what  extent  to 
restrict  the  quantity  of  water  and  other  fluids  drunk  by  diabetics. 
When  so  much  urine  is  voided  that  the  patient's  rest  at  night  is  dis- 
turbed by  acts  of  frequent  micturition,  it  is  always  annoying,  and 
may  be  serious.  The  increased  work  thrown  upon  the  kidneys 
is  less  harmful  than  might  be  supposed,  and  taxes  the  renal  epithelium 
less  than  the  excretion  of  the  solids  of  the  urine.  Protracted  cases  of 
diabetes  do  not  necessarily  exhibit  serious  renal  degeneration. 

For  these  reasons,  if  the  water  drunk  is  restricted,  it  should  be  so 
more  on  account  of  relieving  the  patient  of  an  uncomfortable  con- 
dition than  from  fear  that  the  act  of  passing  so  much  urine  may  be 
injurious  per  se,  and  the  restriction  should  never  be  enforced  too 
suddenly.  As  a  rule,  when  dietetic  regulation  reduces  the  glycosuria 
and  improves  the  patient's  condition  there  is,  part  passu,  a  diminution 
of  thirst  and  in  the  quantity  of  urine  voided.  In  other  words,  the 
polyuria  takes  care  of  itself.  A  reasonable  restriction  of  the  fluids 
allowed  is  to  be  recommended,  but  when  thirst  is  extreme  it  becomes 
unendurable  torture  to  withhold  them  strictly,  and,  moreover,  the 
water  is  apparently  needed  to  wash  out  the  sugar  which  would  other- 
wise accumulate  in  the  blood  and  tissues.  In  fact,  the  occurrence  of 
impending  coma  has  been  postponed  by  flushing  the  circulation  by 
means  of  large  draughts  of  water  or  enemata  of  salt  water. 

When  the  thirst  leads  to  excessive  drinking,  salt  foods  and  condi- 
ments should  be  withheld,  and  some  relief  may  be  obtained  by  suck- 
ing a  slice  of  lemon  or  by  using  a  little  potassium  bitartrate  and 
lemon  juice,  or  dilute  phosphoric  acid  in  water.  The  patient  should 
drink  only  from  a  small  glass,  for  there  is  more  satisfaction  in  drain- 
ing it  than  in  taking  the  same  quantity  of  fluid  from  a  large  goblet 
which  one  is  not  allowed  to  empty.  I  have  known  decided  benefit 
from  adopting  this  simple  means. 

It  is  important  not  to  distress  the  patient  so  much  by  denial  that 
the  nervous  system  suffers  in  consequence. 

Beverages  Forbidden. —  As  a  rule,  patients  do  better  without  al- 
cohol, and  strong  spirits  should  be  interdicted  absolutely  as  well  as 
sweet  and  sparkling  wines,  all  wines  with  "bouquet,"  especially  Ma- 
deira, port,  sweet  sherry,  Sauternes,  and  sweet  champagnes.  No 
punch  or  liqueurs,  cider,  beer,  root-beer,  grape  juice,  ginger  or  sweet 
ales  may  be  allowed.  Soda  water  with  sirup  is  prohibited. 

Beverages  Alloiccd. —  If  it  becomes  necessary  to  give  alcohol  as  a 
tonic  or  stimulant,  an  acid  claret  or  Burgundy,  hock,  or  still  Moselle 


DIABETES   MELLITUS 

may  be  prescribed  diluted  with  mineral  water;  or  a  little  much- 
diluted  brandy,  whisky,  or  unsweetened  gin  may  be  allowed.  Weak 
brandy  sometimes  allays  thirst  better  than  water.  Dry  sherry,  Cha- 
blis,  and  Burton  bitter  ale  are  prescribed  occasionally,  and  the  Cali- 
fornia Riesling  or  Zinfandel  may  be  used.  Bass's  ale  may  be  allowed 
because  the  sugar  which  it  originally  contained  has  been  entirely 
converted  into  alcohol  and  carbonic  acid  (Flint). 

Tea,  alone  or  with  lemon,  coffee,  and  infusion  of  cocoa  nibs, 
sweetened  with  a  quarter  of  a  grain  of  saccharin,  are  allowed.  Choc- 
olate may  be  manufactured  without  sugar  (p.  750).  Buttermilk  and 
koumiss  may  be  given.  They  allay  thirst  and  in  koumiss  the 
milk  sugar  has  been  fermented  into  lactic  acid.  Sour  lemon  or 
orange  juice  in  Vichy  with  a  pinch  of  sodium  bicarbonate  makes  an 
agreeable  and  cooling  draught.  Saccharin  may  be  added.  In  Ger- 
many acorn  coffee  is  sometimes  used. 

As  an  adjunct  to  the  dietetic  treatment,  the  alkaline  mineral 
waters  are  extremely  serviceable,  especially  those  obtained  from  nat- 
ural wells. 

The  baths  and  waters  of  Carlsbad  in  Bohemia,  Ems  in  Germany, 
and  Vichy  and  Contrexeville  in  France  have  achieved  a  considerable 
reputation  for  the  cure  of  diabetes,  and  after  due  allowance  for  the 
improvement  consequent  upon  proper  regimen,  dietetic  regulation, 
and  systematic  habits  of  life  which  are  enforced  at  these  spas,  there 
seems  to  be  special  benefit  derived  from  the  waters  themselves.  Other 
waters  which  may  be  drunk  are  Apollinaris,  Johannis,  Saratoga  Vichy, 
plain  soda  or  potash  water,  Seltzer,  the  alkaline  calcic  Waukesha,  or 
the  different  lithia  waters.  , 

Special  Diabetic  Diets  —  Ebstein's  Diabetic  Diet 
Early  Breakfast. —  One  cup  of  coffee  or  tea  (black),  without  milk 
and  sugar.  White  bread  toasted,  thirty  to  fifty  grams  (1-1%  ozs)  ; 
or  brown  bread  well  buttered  —  butter,  twenty  to  thirty  grains  (1  oz.). 
The  yolk  of  an  egg,  a  little  fat  ham,  or  some  German  sausage,  if  re- 
quired. If  any  food  be  needed  between  this  meal  and  dinner,  let  it  be 
a  cup  of  broth,  with  the  yolk  of  an  egg. 

Dinner. —  Broth,  with  yolk  of  egg  or  marrow  (the  marrow  bone  is 
boiled  for  half  an  hour,  to  solidify  the  marrow).  Peptone  may  be 
added  to  the  broth.  Meat,  one  hundred  and  eighty  grams  (6  ozs.), 
free  from  bone,  roasted,  boiled,  or  stewed  —  beef,  mutton,  pork,  veal, 
fowl,  or  venison  (fat  meat  preferred).  Gravies,  to  be  made  with 
cream  or  yolk  of  egg.  not  flour.  Fish  to  be  served  with  melted 
butter.  Vegetables  prepared  with  much  fat;  puree  of  leguminous 


756         DISEASES  ESPECIALLY   INFLUENCED   BY  DIET 

plants;  salads,  dressed  with  vinegar  and  oil.  The  food  should  be 
well  salted  and  spiced.  After  dinner,  a  cup  of  coffee  or  tea  with  sac- 
charin if  desired. 

Supper. —  One  cup  of  tea  or  broth.  Meat  (roasted),  or  cheese,  or 
an  egg,  or  fish,  caviare.  Bread,  thirty  to  fifty  grams  (1-1%  ozs), 
with  butter,  twenty  to  thirty  grams  (%-l  ozs).  Apples,  pears,  and 
stone-bearing  fruits  are  allowed  in  small  quantities. 

Beverages. —  Ebstein  forbids  absolutely  the  use  of  beer,  limits  the 
use  of  spirits,  and  allows  about  half  a  bottle  of  wine  daily.  If  the 
patient  can  digest  milk  well,  it  is  allowed  in  moderate  doses,  and  cream 
is  especially  recommended. 

In  the  following  diet,  recommended  by  During,  it  will  be  noticed 
that,  contrary  to  most  other  systems,  fat  is  excluded  as  much  as  pos- 
sible. 

During  claims  that  prolonged  boiling  so  alters  the  carbohydrates 
as  to  prevent  them  from  being  eliminated  in  the  urine  as  sugar,  and 
he  gives  his  patients  a  diet  consisting  largely  of  rice  and  fruits 
which  have  been  soaked  in  water  and  boiled  for  several  hours.  The 
details  of  his  regimen  are  as  follows : 

During' s  Diet  for  Diabetes 

Early  Breakfast. —  Milk,  with  a  little  coffee  but  no  sugar  (lime 
water,  to  prevent  milk  from  souring  in  the  stomach)  ;  stale  white 
bread  ad  libitum,  or,  if  it  is  not  well  borne,  oatmeal,  barley,  or  rice 
gruel  made  with  water,  a  little  salt,  but  no  butter. 

Second  Breakfast. —  White  bread,  stale  and  well  baked;  an  egg, 
lightly  boiled;  rice  or  oatmeal  gruel,  with  or  without  milk,  a  break- 
fast-cupful; or  half  a  glass  of  good  red  wine  (with  water  in  certain 
cases). 

Dinner  (taken  between  two  and  three  o'clock). —  Soup,  with  rice, 
barley,  or  oatmeal;  meat,  roasted,  two  hundred  and  fifty  grams  (S1/^ 
ozs.)  (game,  ham,  and  smoked  meats,  as  free  from  fat  as  possible,  are 
permissible)  ;  no  condiments,  no  fatty  sauces;  compote  of  dried  apples, 
plums,  cherries;  dried  peas  or  white  beans  in  some  cases;  green 
vegetables,  asparagus,  French  beans,  carrots,  cauliflower,  cabbage 
(boiled  in  water  with  salt,  not  with  fat  or  stock) ;  dessert  of  a  little 
raw  fruit,  apples,  cherries,  and  one  small  glass  of  red  wine  diluted 
with  water. 

Supper  (about  7  p.  M.). —  Gruel  or  barley,  oatmeal,  or  rice,  with 
salt  (but  no  butter),  and  strained,  which  in  some  cases  may  be  made 
with  milk.  Ice  or  iced  water,  to  relieve  thirst  between  meals. 


DIABETES  MELLITUS  757 

Naunyn's  Diet 

B.  Naunyn  divides  cases  of  diabetes  into  three  varieties  —  mild, 
severe,  and  intermediate.  For  the  most  serious  cases  he  prescribes 
a  diet  of  fat  meat;  the  intermediate  cases  are  treated  at  first  on  an 
exclusive  diet  of  fat  meat,  then,  as  the  sugar  disappears  from  the 
urine,  he  adds  eggs,  milk,  and  a  small  allowance  of  bread  to  the 
diet.  In  mild  forms  he  directs  the  use  of  a  few  green  vegetables, 
salads,  fruits,  and  other  articles,  unless  the  sugar  reappears  in  the 
urine,  when  the  patient  is  to  be  put  back  upon  a  strict  nitrogenous 
diet.  He  claims  that  in  mild  cases  of  diabetes  patients  do  not  re- 
quire more  than  from  sixteen  to  eighteen  ounces  of  meat  a  day,  with 
two  or  three  ounces  of  bread  and  six  or  seven  ounces  of  vegetables. 

Von  Noorden's  Oatmeal  Diet 

Karl  von  Noorden  of  Vienna  advocates  the  use  of  oatmeal  in 
diabetes,  on  the  ground  that  carbohydrates,  especially  in  this  form, 
do  not  yield  low  fatty  acids,  such  as  oxybutyric,  and  give  rise  to  ace- 
tonuria.  The  salted  oatmeal  is  long  boiled,  with  butter,  and  after 
cooling,  beaten  egg  albumen  or  a  vegetable  albumin  is  added,  such 
as  Eobrat  or  rice  albumen.  The  quantity  given  per  diem  comprises, 
oatmeal  250  gram  (S1/^  ozs.),  butter  300  grams  (10  ozs.),  albumin 
100  grams  (3y3  ozs.).  He  also  prescribes  a  little  wine  or  brandy  and 
coffee.  On  this  diet,  which  contains  3,200  calories,  given  every  two 
hours,  he  reports  marked  improvement,  an  eventual  increase  in  car- 
bohydrate toleration.  He  points  out,  however,  that  the  more  severe 
cases  do  better  upon  this  temporary  diet  than  very  mild  ones.  The 
oatmeal  diet  is  continued  for  ten  days  or  a  fortnight,  when  the  ordi- 
nary diabetic  diet  is  gradually  resumed.  The  oatmeal  preparation 
may  be  fried  in  cakes  if  preferred.  It  is  open  to  the  objection  that  it 
contains  a  large  quantity  of  butter,  which  mav  result  in  acidosis  from 
/?-oxybutyric  acid. 

(3)    HYGIENIC   TREATMENT 

Patients  should  guard  themselves  as  far  as  possible  from  taking 
cold,  and  when  possible  should  live  in  a  moderately  warm  and  tem- 
perate climate.  If  their  surroundings  permit,  it  is  important  to  take 
moderate  exercise  and  to  remain  in  the  open  air.  Flannels  should  be 
worn  next  to  the  skin  in  winter,  and  the  body  should  be  kept  always 
warm,  for  there  is  less  heat-producing  power  than  normally.  The 
skin  should  be  maintained  in  good  condition  by  frequent  warm  baths 
or  alternate  hot  and  cold  douching,  dry  rubbing,  or  massage.  All 


758        DISEASES  ESPECIALLY   INFLUENCED  BY  DIET 

muscular  or  nervous  or  mental  fatigue  is  to  be  avoided.  It  is 
claimed  by  Kiilz  that  muscular  exercise  tends  to  increase  the  con- 
sumption of  sugar  or  glycogen  in  diabetes  and  to  lessen  its  elimination 
by  the  kidneys.  This  applies  to  more  robust  patients  only,  for  in  the 
serious  type  of  the  disease  with  great  emaciation  much  exercise  be- 
comes harmful  or  impossible. 

(4)    MEDICINAL   TREATMENT 

The  medicinal  treatment  of  diabetes  is  exceedingly  unsatisfactory. 
In  a  certain  proportion  of  cases  of  diabetes  cure  may  result  by  ex- 
clusive dietetic  treatment.  There  are  others  in  which  the  use  of 
medicines  is  found  to  be  of  some  service,  but  it  may  be  stated  posi- 
tively that  there  are  no  cases  which  are  curable  by  medicines  without 
proper  dietetic  treatment. 

Opium  and  codeia  are  successful  in  some  instances  in  reducing  the 
amount  of  sugar  voided.  Commencing  with  half-grain  doses,  the  lat- 
ter is  to  be  gradually  increased  until  ten  or  fifteen  grains  are  taken 
in  a  day ;  alkalies,  such  as  the  citrates  and  acetates,  are  also  occasion- 
ally found  beneficial.  Clemen's  liquor  arsenici  bromati  has  attained 
success  in  some  hands.  Digestive  tonics,  aromatic  bitters,  mineral 
acids,  and  cod-liver  oil  are  frequently  indicated,  and  strychnine  and 
ergot  are  to  be  employed  as  vasomotor  tonics  when  desired.  They  regu- 
late the  arterial  tension,  and  may  reduce  the  quantity  of  urine  and 
relieve  the  thirst. 

The  nitrogenous  diet  is  apt  to  excite  diarrhoea,  which  may  be 
controlled  by  such  remedies  as  salol,  or  salicylate  of  bismuth. 

For  the  intense  craving  for  food  experienced  by  some  patients, 
with  a  hollow,  sinking  feeling  at  the  epigastrium,  Roberts  recom- 
mends a  two-  or  three-grain  asafoetida  pill  three  times  a  day. 

Diabetic  Coma 

When  coma  supervenes  in  diabetes,  the  patient  is  beyond  all  dieting, 
but  when  it  is  threatened  by  the  appearance  of  drowsiness,  with 
acetonuria,  or  diacetic  or  /?-oxybutyric  acid  in  the  urine,  all  fats 
should  be  withheld  from  the  dietary,  as  the  fatty  acids  are  the  pre- 
cursors of  those  substances.  This  is  especially  true  of  the  lower  fats, 
olein  and  butyric  acid,  rather  than  of  the  higher  fats,  palmitin  and 
stearin.  Hence  an  excess  of  cream  and  butter  is  undesirable  for 
diabetics,  but  such  fats  as  exist  in  the  form  of  lard,  suet,  egg  yolk, 
cod-liver  oil,  olive  and  other  vegetable  oils,  bone  marrow,  meat  fat, 
and  fat  bacon  are  all  good  diabetic  foods.  It  is  established  that  when 
a  moderate  quantity  of  a  carbohydrate  is  ingested  with  such  fats,  they 


RHACHITIS  759 

are  more  completely  oxidized  than  if  eaten  alone,  and  hence  are  less 
liable  to  occasion  acidosis,  which  is  favored  by  starvation  and  a  heavy 
exclusive  meat  diet. 


RHACHITIS  (RICKETS) 

Causation. —  Eickets  is  a  disease  of  malnutrition.  The  fault  may 
lie  in  a  hereditary  weakness  of  the  digestive  organs,  or  the  influence 
of  some  concurrent  disease,  but  the  majority  of  cases  are  directly 
caused  by  improper  or  insufficient  food.  This  food  may  be  the  breast 
milk  of  a  mother  or  wet  nurse,  who  is  herself  enfeebled  by  chronic 
disease,  by  oft-repeated  pregnancies,  or  whose  mammary  secretion  is 
modified  by  dietetic  errors,  loss  of  sleep,  emotional  or  neurotic  dis- 
orders, or  the  milk  supply  may  be  insufficient  from  too  long-continued 
nursing  or  the  intervention  of  pregnancy,  or  some  other  factor. 
Breast-fed  infants  may  become  rhachitic  if  the  milk  is  watery,  of  low 
specific  gravity,  too  poor  or  too  rich  in  fat  or  in  lactose.  The  poor, 
for  reasons  of  economy,  often  suckle  their  children  for  too  long  a 
period  —  in  fact,  until  they  are  two  years  of  age  —  but  even  before 
weaning  them  they  allow  them  to  go  to  the  table  and  share  in  the 
general  diet  of  fried  fish,  pickles,  potatoes,  pork,  raw  fruits,  beer,  etc. 
Children  treated  in  this  manner  are  especially  prone  to  develop 
rickets.  In  all  doubtful  cases  the  milk  of  the  mother  or  nurse  should 
be  analyzed  before  weaning,  and  an  effort  made  to  improve  its  quality. 
If  the  child  is  already  weaned,  the  cause  of  the  rhachitic  condition 
may  be  a  poorly  selected  diet,  such  as  condensed  milk,  or  a  patent  or 
proprietary  "  baby  food "  with  insufficient  fat  and  earthy  salts  and 
excess  of  starch. 

Eickets  has  been  experimentally  produced  by  Cheadle,  Guerin, 
and  others  in  young  animals  by  depriving  them  of  animal  fats  and 
earthy  salts.  It  is  caused  by  withholding  all  lime  salts  from  the 
food  (Voit),  but  especially  calcium  phosphate,  and  young,  growing 
animals  failing  to  receive  a  fresh  supply  absorb  lime  salts  from 
bones  already  ossified  for  the  benefit  of  the  newer  ones,  and  thus 
all  the  bones  become  soft.  Baginsky  found  that  this  process  is  ex- 
aggerated in  young  animals  by  the  presence  of  lactic  acid  in  the 
food,  and  Wegner  proved  that  phosphorus  has  a  similar  effect. 
Forster  has  calculated  from  the  lime  ordinarily  present  in  milk  that 
an  infant  four  months  of  age  receives  lo1/^  grains  each  day.  Indiges- 
tion lessens  hydrochloric-acid  secretion  and  increases  lactic-acid  for- 
mation, and  reduces  absorption  of  lime  salts. 

Starchy  and  saccharine  foods  not  onlv  contain  little  or  none  of 


760        DISEASES  ESPECIALLY   INFLUENCED   BY   DIET 

the  necessary  lime,  but  readily  undergo  lactic-acid  fermentation,  thus 
intensifying  the  rhachitic  processes. 

Bottle-fed  infants  are  very  subject  to  rickets,  especially  if  the  milk 
be  sterilized. 

Prophylaxis. —  The  best  prophylactic  against  rickets  is  nursing  dur- 
ing the  first  year  by  a  healthy  mother  or  a  carefully  selected  wet 
nurse.  It  is  a  very  common  practice  in  this  country  for  mothers  in 
good  circumstances  to  wean  their  babies  too  early,  and  without  a  phy- 
sician's advice  to  resort  to  one  of  the  much-advertised  patent  infant 
foods,  with  the  result  above  described. 

Dietetic  Treatment. —  The  dietetic  treatment  of  rhachitis  in  a 
weanling  consists,  first  of  all,  in  supplying  good  fresh  cow's  milk  modi- 
fied to  resemble  as  closely  as  possible  the  best  mother's  milk.  It  is 
important  that  the  milk  should  contain  sufficient  fat,  and  it  should  be 
modified  accordingly  by  the  addition  of  cream  or  oil.  (See  Modified 
Milk,  p.  103.) 

If  the  child  must  be  bottle  fed,  the  milk  temporarily  may  be  pas- 
teurized in  order  to  diminish  the  liability  of  its  fermentation  in  the 
alimentary  canal,  and  among  the  poor,  who  cannot  afford  to  purchase 
modified  milk,  the  ordinary  milk  as  soon  as  purchased  should  be 
heated,  and  a  few  grains  of  bicarbonate  of  sodium  may  be  added  to  it. 
A  plug  of  previously  baked  cotton  should  be  used  in  the  bottle  in  place 
of  a  cork.  When  given,  the  milk  may  be  diluted  with  barley  water,  or, 
if  constipation  be  present,  with  oatmeal  water.  These  waters  are  made 
by  boiling  a  tablespoonful  of  pearl  barley  or  of  good  oatmeal  in  a  pint 
of  water  until  the  meal  is  completely  softened.  A  little  salt  is  then 
added,  and  the  mass  is  strained  through  a  fine  cloth.  It  is  advisable 
also  to  add  milk  sugar.  The  proportion  of  milk  for  the  diluent  should 
be  half-and-half  for  the  first  six  weeks  of  infancy ;  after  this  the  pro- 
portion is  to  be  gradually  increased,  and  when  six  months  of  age  the 
infant  should  be  given  three  parts  milk  and  one  part  diluent.  The 
quantity  of  milk  is  to  be  continuously  increased,  and  at  the  ninth 
month  it  may  be  in  the  proportion  of  four  to  one,  and  at  the  end  of  the 
year  dilution  is  no  longer  required. 

Very  young  infants  who  are  fed  by  artificial  means  should  not  be 
given  farinaceous  food  too  freely.  In  the  first  two  or  three  months  of 
infant  life  the  saliva  —  from  deficiency  in  ptyalin  —  is  incapable  of 
digesting  much  starch,  and  starch  is  also  poorly  digested  by  the  pan- 
creatic juice  in  the  intestine.  Starch,  therefore,  acts  as  a  foreign  body 
and  a  gastrointestinal  irritant,  and  passes  through  the  alimentary 
canal  unaltered.  Tt  is  advisable  in  all  rachitic  children  to  restrict  the 
giving  of  farinaceous  foods  until  some  time  after  the  period  when  they 


RHACHITIS  761 

are  often  allowed,  and,  as  a  rule,  children  having  rickets  should  not  be 
fed  any  starchy  food  until  after  the  twelfth  or  fourteenth  month  ex- 
cept as  a  diluent  of  milk  as  above  described.  They  need  fats  much 
more  than  starches  or  sugars. 

There  are  some  apparent  exceptions  to  this  rule  in  which  infants  be- 
come seemingly  robust  while  fed  upon  amylaceous  foods  at  a  very 
early  period,  but  they  are  less  healthy  as  they  grow  older  or  exhibit 
malnutrition  or  some  constitutional  weakness.  Such  exceptions  by  no 
means  controvert  the  value  of  the  rule  in  general,  as  above  stated. 

Preparations  of  condensed  milk  which  contain  large  quantities  of 
sugar  are  sometimes  given  to  infants,  and  they  produce  a  prompt  in- 
crease in  weight,  due  to  stored-up  fat  and  water,  but  the  appearance 
in  these  cases  is  deceptive,  and  the  muscles  and  other  tissues  are  less 
firm  and  strong  than  they  should  be.  This  is  proved  by  the  fact  that 
children  erroneously  fed  in  this  way  succumb  readily  to  various  dis- 
eases of  infancy,  especially  to  diarrhceal  troubles.  After  the  first  year 
a  little  of  some  malted  or  predigested  form  of  starchy  food  may  be 
added  to  the  milk. 

Whenever  amylaceous  food  is  mixed  with  the  milk  it  should  previ- 
ously be  converted,  as  far  as  possible,  by  diastase  into  dextrin  or  glu- 
cose, and  added  rather  with  the  object  of  mechanically  preventing 
the  formation  of  coagulas  of  casein  than  with  the  idea  of  feeding  the 
infant  upon  a  substance  which  its  digestive  organs  are  not  yet  fitted 
to  act  upon.  J.  Lewis  Smith  says :  "  If  a  heaping  teaspoonf ul  of 
barley  flour  be  boiled  in  twenty-five  teaspoonfuls  of  water,  and  when 
it  is  lukewarm  ten  or  fifteen  drops  of  diastase  be  added  to  it,  the 
gruel  in  a  few  minutes  becomes  much  thinner  from  the  digestion  of 
starch,  and  it  is  a  useful  adjuvant  to  the  milk  employed  in  the 
nursery,  especially  for  infants  over  the  age  of  six  months."  At  this 
time  or  later  a  little  albuminous  food  in  the  form  of  mutton  or  chicken 
broth  or  the  expressed  juice  of  rare  roast  beef  or  beefsteak  may  be 
given. 

After  a  year  or  fourteen  months  the  diet  should  consist  of  cow's 
milk,  cream,  beef  juice  squeezed  from  a  fresh  steak,  and  broths,  and 
stale  bread  crumbs  in  milk  may  be  added.  Later,  the  child  may 
take  scraped  beef  or  a  raw  beef  sandwich  made  with  thin  layers  of 
bread  and  butter  with  meat  pulp  between  them.  Beef  tea,  mutton, 
and  chicken  broths  are  good.  Fresh  fruit  juice,  especially  orange 
juice,  is  excellent.  A  little  sweet  currant  jelly  added  to  the  meat  will 
improve  its  flavor  for  older  children  who  object  to  taking  it.  When 
a  year  and  a  half  old  the  child  may  be  given  eggs,  either  beaten  with 
milk  and  sweetened  or  soft-cooked.  If  attacks  of  diarrhrea  supervene, 


762         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

it  will  be  well  to  discontinue  the  meat  broths  temporarily  and  place 
the  child  for  a  few  days  on  a  diet  of  koumiss  or  pancreatinized  milk. 
In  some  cases  maltine  is  found  to  agree  well  with  rhachitic  children, 
and  if  diarrhoea  does  not  exist  they  should  be  given  pure  Norwegian 
cod-liver  oil  three  times  a  day  in  doses  of  a  few  drops  for  a  young 
infant,  up  to  a  teaspoonful  for  a  child  a  year  or  two  old.  Older  chil- 
dren should  have  abundant  fat,  in  the  form  of  fresh  butter  on  bread, 
or  cream  upon  stewed  fruit  or  baked  apples.  Olive  oil  is  also  service- 
able. Fothergill  wrote :  "  The  liquid  fat  of  fried  bacon  is  most 
digestible,  and  the  child  should  be  allowed  to  dip  its  bread  in  it  or 
have  it  crumbed  into  the  fluid  fat."  Or  it  occasionally  may  be  given 
a  piece  of  bacon  to  suck. 

Inunctions  of  two  or  three  tablespoonfuls  of  olive  oil  may  be  given 
daily  over  the  legs  and  abdomen. 

Ehachitic  children,  on  account  of  their  poor  nutrition,  usually  have 
a  deficient  number  of  teeth  or  their  teeth  are  imperfect  or  quickly 
decay.  It  is  therefore  important  that  when  they  have  passed  the  first 
dentition  food  should  be  given  them  in  a  state  of  fine  subdivision, 
otherwise  it  will  be  bolted  without  mastication  and  gastrointestinal  dis- 
order will  result.  Meat  should  be  hashed  thoroughly  or  pounded  in 
a  mortar,  and  solid  meat  never  should  be  given  the  child  to  masticate 
until  it  is  over  two  years  of  age.  Potatoes  should  be  given  baked  in  a 
soft  and  mealy  form. 

Some  breast-fed  infants  may  become  rickety,  while  others  ill-fed 
by  artificial  means  may  not,  and  the  extraordinary  instances  of  tolera- 
tion of  improper  food  which  one  constantly  finds  among  the  children 
of  the  ignorant  poor,  at  times  severely  test  one's  faith  in  dietetic  rules, 
but  much  allowance  should  be  made  for  the  constitution  of  individuals 
and  for  race  characteristics.  The  subsequent  history  of  wrongly  fed 
children  often  points  directly  to  original  faults  in  diet  which  have 
affected  the  general  nutrition  of  the  body,  although  the  immediate 
effect  of  such  errors  may  not  have  been  apparent. 

Aids  to  Dietetic  Treatment. —  Ehachitic  babies,  as  well  as  older 
children,  should  be  weighed  at  regular  intervals  as  an  important  guide 
for  their  correct  feeding. 

In  rickets  more  or  less  gastric  catarrh  is  commonly  present,  which 
interferes  with  normal  digestion  and  absorption,  and  appropriate  me- 
dicinal remedies  should  be  employed  to  regulate  this  condition  when 
necessary.  There  is  often  excessive  acidity  in  the  stomach  which  may 
be  neutralized  by  sodium  bicarbonate.  The  hygienic  treatment  in  con- 
junction with  dietetic  measures  is  of  the  utmost  importance.  Eickety 
children  should  live  outdoors  in  all  seasonable  weather,  and  it  is  bet- 


SCURVY  763 

ter  for  them  to  remain  out  in  fresh,  cold  air  than  be  kept  at  home  in  a 
damp,  dark,  overheated,  and  badly  ventilated  tenement.  They  should 
be  bathed  frequently  in  order  to  keep  the  skin  in  as  good  condition  as 
possible,  and  prevent  the  occurrence  of  skin  diseases,  which  are  a  com- 
mon accompaniment  of  malnutrition.  They  should  be  kept  quiet  and 
not  worried,  and  if  they  are  weak  and  feeble,  great  care  should  be  exer- 
cised in  handling  them  and  placing  them  in  proper  positions  upon 
beds  which  are  firm  but  not  hard,  in  order  to  prevent  the  weakened 
bones  from  becoming  deformed  by  pressure. 

SCURVY 

Causation. —  Scurvy  is  a  disease  dependent  upon  malnutrition, 
which  is  customarily  attributed  to  lack  of  fresh  vegetables  in  the  diet ; 
but  this  statement  is  somewhat  vague,  in  that  it  is  not  known  ex- 
actly which  articles  of  diet  are  most  liable  to  produce  the  disease  by 
their  absence,  although  many  believe  that  the  cause  is  due  to  deficiency 
of  salts  whose  acids  —  citric,  malic,  lactic,  acetic,  and  tartaric  —  form 
carbonates,  but  no  preventive  food  has  been  found  which  is  abso- 
lutely successful  in  all  cases.  At  all  events,  it  is  a  disease  due  to 
omission  and  not  consumption  of  certain  foods,  and  it  depends  rather 
upon  the  quality  than  quantity  of  food.  In  opposition  to  the  theory 
that  the  want  of  fresh  vegetables  acts  as  a  cause  of  scurvy  in  man,  the 
fact  is  stated  by  Lieutenant  Greely  that  among  the  Danish  Eskimos, 
who  have  a  population  of  ten  thousand,  not  a  pound  of  vegetables  nor 
a  dozen  pounds  of  bread  per  man  are  eaten  annually,  and  yet  they  are 
practically  free  from  the  disease,  and  the  same  statement  is  made  in 
regard  to  the  most  northern  tribes  of  Eskimos  of  pure  blood  who  were 
studied  by  Lieutenant  Peary,  and  also  in  regard  to  the  natives  of  the 
Alaskan  archipelago  and  some  tribes  of  North  American  Indians  who 
can  not  include  either  vegetables  or  cereals  in  their  food.  The  disease 
may  arise  among  those  who  have  lived  for  some  time  in  bad  hygienic 
surroundings  and  in  damp,  dirty  quarters,  and  who  have  been  subjected 
to  mental  depression,  monotony  of  occupation  and  diet,  or  excessive 
work  and  fatigue,  as  well  as  the  abuse  of  alcohol.  It  has  often  been 
known  in  overcrowded  prisons  and  barracks.  It  is  therefore  possible 
for  scurvy  to  occur  in  any  part  of  the  world  among  men  affected  by 
these  conditions. 

When  the  potato  crop  failed  in  Great  Britain  and  Ireland  in  1846 
scurvy  became  very  prevalent.  In  the  war  of  the  Crimea  twenty-three 
thousand  cases  occurred  among  the  French  troops  alone. 

In  the  British  arctic  expedition  of  1875-'?6  over  48  per  cent  of  all 


764         DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

the  men  suffered  from  scurvy,  and  a  still  larger  percentage  existed 
among  those  who  were  exempt  from  field  service  and  outdoor  life. 

Major  Woodruff,  referring  to  scurvy  in  the  United  States  Army, 
writes :  "  If  transportation  is  so  deficient  that  only  bacon,  hard-tack, 
and  coffee  can  be  carried,  actual  scurvy  is  the  result.  The  company 
commander  must  secure  something  else  for  his  men.  The  lack  of 
fresh  vegetables  and  fresh  meat  is  the  chief  fault.  Why  fresh  things 
are  needed  is  not  known,  but  it  is  believed  to  be  due  to  the  fact  that  the 
body  thus  receives  certain  salts  and  unknown  substances  necessary  as 
stimulants  or  tonics  to  the  tissues,  which  salts  and  substances  are  de- 
stroyed by  the  usual  methods  of  preservation.  Men  may  live  for  many 
years  without  tasting  such  articles  of  diet,  though  it  is  rare  for  [civil- 
ized] man  to  be  denied  all  three  —  meats,  fresh  vegetables,  and  fresh 
fruits.  If  they  are  so  denied  they  are  not  possessed  of  that  health 
which  permits  of  the  highest  mental  and  physical  development." 

Scurvy  contributed  15  per  cent  to  the  death  rate  from  diseases  in 
the  late  Civil  War,  and  it  was  formerly  prevalent  among  seafaring 
men  when  upon  long  voyages,  who  lived  upon  salt  pork  or  pickled 
meats;  but  the  disease  is  encountered  much  less  often  at  the  present 
time,  owing  to  the  better  means  of  preserving  foods,  securing  variety 
in  diet,  and  better  hygiene.  The  regulations  of  boards  of  trade  usually 
require  that  antiscorbutic  foods  and  remedies  should  be  carried  upon 
vessels,  and  the  development  of  scurvy  on  board  ship,  unless  in  excep- 
tional cases  of  shipwreck  or  in  voyages  prolonged  beyond  the  expected 
limit,  subjects  the  captains  or  owners  to  indictment  for  criminal  neg- 
ligence. The  English  law  early  required  that  lime  juice  should  be 
carried  on  long  voyages,  and  this  formerly  earned  the  nickname  of 
"  lime  juicers "  for  British  sailors.  Many  almshouses  have  similar 
regulations. 

Garrod  holds  that  scurvy  is  caused  by  absence  of  potash,  for  in  this 
disease  the  blood  is  deficient  in  potassium  salts.  He  regards  this  fact 
also  as  an  explanation  of  the  muscular  weakness  which  is  a  prominent 
feature,  and  observes  that  all  good  antiscorbutics  —  fresh  milk,  meat, 
lemons,  oranges,  and  fresh  vegetables  —  contain  abundant  potash. 

His  theory  is  modified  by  Immermann,  who  believes  that  a  tem- 
porary lack  of  potassium  salts  may  cause  trophic  disorders,  which  may 
continue  for  some  time  after  the  deficiency  in  salts  has  been  made 
good,  and  Duchek  found  that  in  exacerbations  of  symptoms  occurring 
in  scurvy  there  may  be  an  increased  elimination  of  potassium  salts  in 
the  urine.  The  body  is  capable  of  retaining  and  re-using  its  various 
salts  for  a  considerable  time,  so  that  withdrawal  of  potash  does  not 
necessarily  induce  scurvy  at  once  (Bauer). 


SCURVY  765 

W.  P.  Northrup  and  Crandall  investigated  the  causes  of  scurvy  in  a 
number  of  infants,  and  report  that  the  employment  of  proprietary 
foods  which  for  various  reasons  are  substituted  by  the  mother  for  fresh 
food  is  the  most  important  cause  of  infantile  scurvy,  and  "  even  fresh 
milk  added  in  small  proportions  is  not  sufficient  to  insure  perfec- 
tion." Their  report  continues : 

"  The  exact  diet  is  known  in  thirty-three  cases.  We  find  that  twelve 
of  these  children  (36  per  cent)  were  fed  on  a  proprietary  food  exclu- 
sively, six  (18  per  cent)  had  received  an  exclusive  diet  of  condensed 
milk  or  evaporated  cream,  while  three  received  a  combination  of  these 
two  foods.  Over  63  per  cent,  therefore,  were  fed  upon  a  diet  of  pro- 
prietary foods  and  condensed  milk.  Two  children  received  sterilized 
milk  exclusively,  and  three  a  weak  mixture  of  milk  and  water.  One 
was  fed  on  condensed  milk,  one  on  boiled  and  peptonized  milk,  and  one 
on  barley-water. 

"  It  is  a  significant  fact  that  the  country  which  furnishes  most  of 
the  literature  of  scorbutus  in  children  is  the  same  which  is  posted  from 
end  to  end  with  advertisements  of  proprietary  foods." 

Louis  Starr  furnishes  a  list  of  the  common  dietetic  causes  of  scurvy 
in  infants,  as  follows  (they  will  be  seen  to  be  very  diverse)  : 

"  The  different  proprietary  infants'  foods  administered  without  or 
with  slight  addition  of  cow's  milk;  these  foods  are  responsible  for  the 
greatest  number  of  cases,  and  the  variety  most  harmful  depends  greatly 
upon  the  degree  to  which  it  is  used;  oatmeal  or  wheat  gruel;  barley 
and  other  farinaceae  administered  with  water  alone  or  with  water  and 
insufficient  cow's  milk;  condensed  milk  and  water;  sterilized  milk; 
properly  modified  milk  mixtures,  but  subjected  to  a  temperature  of 
212°  F.  from  thirty  minutes  to  an  hour  or  more;  too  dilute  milk-and- 
cream  mixtures;  laboratory  mixtures  with  too  low  albuminoid  per- 
centages." Scurvy  is  found  more  frequently  in  infants  reared  in  lux- 
ury than  in  the  very  poor,  because  the  parents  of  the  former  can  afford 
to  buy  prepared  foods. 

Scurvy  in  infants  presents  definite  peculiarities  due  to  subperi- 
osteal  effusions  of  blood  along  the  femoral  and  tibial  shafts,  which 
are  accompanied  by  hypersesthesia,  local  pain,  tenderness,  swelling, 
and  immobility.  Occasionally  the  cranial  bones,  ribs,  and  bones  of 
the  arms  are  involved.  The  pain  and  immobility  formerly  led  to 
mistaken  diagnoses  of  rheumatism,  spinal  cord  disease,  etc.  Haema- 
turia  may  occur. 

Prophylaxis. —  So  long  as  the  hygienic  conditions  are  good  and  the 
food  is  of  the  best  quality  and  variety,  and  if  proper  discipline  and 
regular  habits  of  eating  and  sleeping  are  insured,  scurvy  may  be  pre- 


766        DISEASES  ESPECIALLY  INFLUENCED  BY  DIET 

vented  among  soldiers  and  sailors,  although  fresh  vegetables  may  not 
be  obtainable.  On  American  ships  potatoes  are  always  used.  Cran- 
berries keep  well  and  are  excellent  antiscorbutic  food.  For  travelers 
in  the  far  North,  Nordenskiold  advised  the  use  of  cloud  berries  (Eubus 
chamcemorus) . 

The  introduction  of  canned  and  compressed  vegetables  in  seamen's 
rations  has  done  much  to  prevent  scurvy,  but  fresh  food  is  always  to 
be  preferred  to  preserved  food  of  any  kind.  Dried  legumes  are  quite 
useless. 

Dietetic  Treatment. —  In  mild  cases  of  scurvy  of  comparatively 
short  duration  patients  rapidly  improve  under  proper  dietetic  treat- 
ment if  it  can  be  obtained.  The  juice  of  two  or  three  limes  or  lem- 
ons, or  a  few  fresh  vegetables  eaten  daily,  may  be  all  that  is  necessary, 
and  the  former  is  one  of  the  best  preventives  as  well  as  curative 
agents. 

Sir  A.  E.  Wright  dissents  from  this  view,  at  least  in  regard  to  such 
cases  as  may  suffer  from  bleeding  from  the  gums.  He  claims  that 
the  acids,  tartaric,  and  citric,  have  a  decided  inhibitory  action  upon 
intravascular  coagulation  when  given  per  os,  and  maintains,  contrary 
to  general  experience,  that  in  scurvy  with  persistent  hemorrhage  the 
use  of  fresh  lemon  juice  tends  to  keep  up  the  oozing  of  the  blood.  He 
says  that  the  neutral  citrates  and  tartrates  do  not  act  in  this  manner, 
and  they  should  therefore  be  prescribed  instead  of  fresh  lemon  juice. 
This  view  is  theoretical,  and  opposed  to  much  practical  experience. 

Stomatitis  is  often  the  most  prominent  symptom,  and  if  the  mouth 
is  very  tender,  the  gums  are  swollen  and  bleed  readily,  and  the  stom- 
ach is  irritable,  the  diet  should  be  limited  to  fluid  or  some  solid  food 
which  requires  no  mastication.  Beef  tea,  broths  and  meat  soups  thick- 
ened with  vegetables,  fresh  vegetables,  purees,  eggs,  and  milk  are  rec- 
ommended. To  these  substances  the  juice  of  two  or  three  fresh 
oranges,  limes,  or  lemons  should  be  added.  If  the  patient  is  able  to 
masticate  food  thoroughly  and  the  stomach  is  not  too  feeble,  fresh 
meat,  baked  or  mashed  potatoes,  cabbage,  sauerkraut,  salads  and 
"  greens,"  such  as  water  cress,  fresh  mustard,  or  radishes,  may  be 
given.  The  citrate  of  iron,  vinegar,  acetic  acid  and  potassium  chlo- 
rate and  bitartrate  have  all  proved  beneficial.  During  the  Civil  War 
the  expressed  juice  of  sorghum  was  tried  with  some  success. 

The  treatment  of  scurvy  in  children  consists  in  discarding  all  pro- 
prietary foods,  and  then  if  the  disease  has  not  progressed  too  far,  im- 
provement and  cure  rapidly  follow  change  to  a  normal  diet  of  mother's 
milk  or  fresh  cow's  milk,  expressed  beef  juice,  and  a  little  fresh  orange 
or  peach  juice. 


ADDISON'S  DISEASE  767 

The  following  dietary  is  recommended  by  Louis  Starr  for  scurvy  in 
an  infant  eight  months  old : 

"At  7  A.  M.,  cream,  y2  ounce;  milk,  -iy2  ounces;  milk  sugar,  1 
drachm ;  water,  3  ounces.  At  9  A.  M.,  one  or  two  teaspoonf uls  of  fresh 
orange  juice,  according  to  the  effect  on  the  bowels.  At  10.30  A.  M., 
same  as  7  A.  M.  At  11.30  A.  M.,  two  teaspoonfuls  of  raw  beef-juice, 
free  from  fat,  and  with  little  salt.  At  1  P.  M.,  one  to  two  teaspoonfuls 
of  fresh  orange  juice.  At  2  p.  ii.,  same  as  at  7  A.  M.  At  3  P.  M., 
two  teaspoonfuls  of  raw  beef-juice  with  salt.  At  5  p.  M.,  one  to  two 
teaspoonfuls  of  fresh  orange  juice.  At  6  p.  jr.,  same  as  at  7  A.  M. 
At  8  P.  M.,  two  teaspoonfuls  of  raw  beef-juice  with  salt.  At  10  p.  M., 
same  as  at  7  A.  n. 

"  A  substitute  for  orange  juice  may  consist  in  scraped  ripe  apple  or 
fresh  grape  juice.  Iron  is  indicated.  The  body  may  be  gently  rubbed 
with  warm  olive  oil." 

H.EMORRHAGIC  PURPURA 

With  regard  to  idiopathic  purpura,  which  sometimes  appears  in 
well-nourished  subjects,  it  has  been  stated  that  a  non-stimulating 
diet,  by  reducing  the  activity  of  the  heart,  may  prevent  the  recur- 
rence of  hemorrhages.  Bauer  says :  "  Such  patients  should  take  all 
foods  and  drinks  cool,  and  never  in  large  quantities  at  a  time;  they 
should  abstain  altogether  from  alcohol,  and  milk  is  to  be  recom- 
mended for  its  easy  toleration  in  these  cases." 

The  dietetic  treatment  recommended  for  scurvy  should  be  employed 
in  these  cases,  but  unfortunately  it  is  usually  less  successful. 

DIET  IX  MISCELLANEOUS  DISEASES 

ADDISON'S  DISEASE 

The  aetiology  of  this  affection  is  somewhat  obscure,  but  in  the  major- 
ity of  instances  it  results  from  tuberculosis  or  other  disease  of  the 
adrenal  bodies,  perhaps  associated  with  functional  or  organic  change 
in  the  neighboring  sympathetic  ganglia. 

At  first  no  dietetic  treatment  is  required,  but  in  advanced  cases 
there  is  always  weakness  of  the  digestive  system,  and  vomiting  becomes 
a  persistent  symptom.  There  is  also  progressive  inanition,  which  be- 
comes extreme.  The  diet,  therefore,  should  be  of  a  light  and  easily 
digestible  character.  In  some  of  the  advanced  cases  the  best  results 
are  obtained  from  an  exclusive  milk  diet.  For  others,  when  milk  is 


768  DIET  IN   MISCELLANEOUS  DISEASES 

not  well  borne,  the  diet  should  consist  of  beef  or  mutton  broth,  with 
eggs  beaten  with  milk  or  sherry,  gruels  with  added  milk  extracts  or 
peptonoids,  custard,  rennet,  milk  toast,  imperial  granum,  somatose, 
or  somatogen. 

Nourishment  should  be  given  at  short  intervals,  at  least  once  in 
three  hours,  and  the  patient  should  be  encouraged  to  take  all  that  he 
can  possibly  digest.  The  intermittent  vomiting  may  necessitate  the 
use  of  nutrient  enemata.  Champagne  may  be  retained.  See  diet  for 
Vomiting  (p.  603). 

OSTEOMALACIA 

The  dietetic  treatment  of  the  condition  of  osteomalacia  is  sug- 
gested by  what  is  known  of  its  aetiology,  but  the  results  are  seldom 
encouraging.  It  is  characterized  by  progressive  softening  of  the  bones, 
a  disease  in  which  the  salts,  especially  the  carbonate  and  phosphate  of 
lime,  are  reduced  to  about  30  per  cent  of  the  normal  quantity. 

It  is  not  known  definitely  in  what  manner  these  salts  are  dissolved 
out  of  the  bony  structures,  and  excess  of  both  lactic  and  carbonic  acid 
have  been  regarded  as  probable  solvents.  It  is  not  proved  that  a  defi- 
ciency of  salts  in  the  diet  causes  the  disease,  which  has  been  observed 
in  well-fed  subjects.  It  is,  however,  customary  to  arrange  the  diet 
with  regard  to  furnishing  an  abundance  of  salts  in  fresh  green  veg- 
etables together  with  such  foods  as  eggs  and  meat. 

It  is  advisable  also  to  prescribe  cod-liver  oil  either  alone  or  in  com- 
bination with  various  phosphates  or  hypophosphites,  and  this  food 
proves  on  the  whole  the  most  serviceable.  Trousseau  thought  that  it 
cured  one  or  two  of  his  cases. 

EXOPHTHALMIC  GOITRE 

It  is  only  very  advanced  cases  of  exophthalmic  goiter  with  consider- 
able cardiac  palpitation  that  require  careful  dieting.  The  indications 
for  treatment  are  to  support  the  strength  and  avoid  flatulency  and 
constipation,  and  any  substances  liable  to  increase  palpitation  or  ex- 
cite the  nervous  system  should  be  withheld.  Hence,  stimulants  of  all 
kinds  should  be  avoided.  Tea,  coffee,  alcohol,  condiments,  and  tobacco 
are  all  forbidden,  as  are  also  sugar,  sweets,  pastry,  fried  food,  and 
"  made  dishes." 

The  food  should  be  plainly  cooked,  and  consist  of  abundant  meats, 
milk,  fats  (such  as  cream,  butter,  and  cod-liver  oil),  carefully  pre- 
pared cereals,  fresh  fruits,  and  green  vegetables. 


CHRONIC  LEAD  POISOXIXG  769 

The  theory  has  been  advanced  that  proteid  foods  should  be  with- 
held in  this  disease,  on  the  ground  that  they  may  intensify  the  nervous 
symptoms,  but  this  does  not  accord  with  my  experience  in  a  very  large 
number  of  these  cases.  It  would  doubtless  be  ill-advised  to  order 
an  exclusive  proteid  diet,  but  anemia  is  often  a  prominent  feature  and 
the  goitrous  case  is  always  made  worse  when  the  heart  muscle  is 
weakened  by  anaemia,  hence  it  is  desirable  to  employ  a  mixed  dietary 
of  animal  and  vegetable  food,  avoiding  such  substances  only  as  may 
produce  dyspepsia,  as  indicated  above.  Karl  von  Noorden  classes  this 
disease  among  the  few  which  like  tuberculosis  and  diabetes  may  be 
benefited  by  forced  feeding  as  described  on  page  515. 

CHRONIC  LEAD  POISONING 

Causation. —  Chronic  lead  poisoning  is  common  among  all  artisans 
or  mechanics  who  work  much  with  lead  in  any  form,  but  especially 
white  lead.  Plumbers  and  house  painters  are  therefore  particularly 
subject  to  it.  It  also  may  be  acquired  by  eating  improperly  tinned  or 
hadly  soldered  canned  food,  although  such  cases  are  usually  acute. 
(See  Lead  Poisoning,  p.  430,  and  Canning,  p.  312.)  It  is  sometimes 
caused  by  using  drinking  water  which  has  passed  through  new  lead 
pipes.  When  present  in  the  strength  of  only  one  one-hundredth  of  a 
grain  to  the  gallon  it  may  cause  neuritis  with  colic,  wrist-drop  and 
other  symptoms. 

The  cheap  ale,  or  "  four  ale,"  as  it  is  called,  sold  in  London  to  the  low- 
est classes,  has  been  sometimes  kept  in  contact  with  pewter  pipes  until 
it  contained  toxic  quantities  of  lead.  Lead  is  occasionally  contained 
in  poisonous  amount  in  beer  or  wine  which  has  been  contaminated  by 
the  metal  during  its  careless  manufacture.  Some  persons  are  exceed- 
ingly susceptible  to  lead,  and  cases  are  recorded  of  poisoning  from  the 
medical  use  of  a  few  doses  of  lead  and  opium  pills,  and  also  from  that 
of  cosmetics  containing  white  lead. 

Dietetic  Treatment. —  Chronic  lead  poisoning  is  always  accompanied 
by  constipation,  and  it  is  desirable  to  overcome  this  difficulty  by 
such  foods  as  will  keep  the  bowels  actively  open.  Fresh  fruits  and 
coarse  cereals  (such  as  oatmeal,  cornmeal,  wheaten  grits,  Graham 
bread),  and  molasses  are  recommended,  with  such  other  foods  and 
regulations  as  are  given  under  the  heading  of  the  Treatment  of  Con- 
stipation (p.  636). 

Water  should  be  drunk  in  large  quantity,  not  solely  to  increase  the 
digestive  secretions  and  keep  the  feces  moist,  but  to  act  as  a  diluent 
and  aid  in  washing  out  the  poison. 
51 


770  DIET  IN   MISCELLANEOUS  DISEASES 

Lemonade,  acidulated  with  dilute  sulphuric  acid,  fifteen  drops  to 
the  tumblerful,  or  with  a  similar  dose  of  aromatic  sulphuric  acid,  is 
much  in  vogue  as  a  prophylactic  beverage,  for  it  forms  an  insoluble 
lead  sulphate  from  the  more  soluble  carbonate  or  other  salts  of  lead 
which  may  have  reached  the  stomach  by  being  taken  with  food  or 
drink.  This  insoluble  salt  is  not  absorbed,  and  hence  poisoning  may 
be  averted. 

Men  employed  in  the  manufacture  of  white  lead  or  other  prep- 
arations of  lead  believe  that  drinking  milk  freely  as  a  beverage  is 
prophylactic  against  poisoning,  but  it  is  doubtful  whether  it  acts  other- 
wise than  as  a  good  diuretic. 

DIETETIC    DIFFICULTIES   ARISING   FROM   ASSOCIA- 
TION OF  DISEASES 

There  are  certain  diseases  and  conditions  which  are  not  infre- 
quently associated  in  the  same  patient,  the  dietetic  treatment  of  each 
of  which  may  be  directly  opposed  to  that  of  the  other.  Such,-  for 
example,  are:  (1)  Diabetes  and  chronic  Bright's  disease,  the  former 
requiring  chiefly  meat,  the  latter  none;  (2)  extreme  leanness  and 
chronic  gastric  catarrh,  the  former  condition  requiring  fats,  starches, 
and  sugars,  the  latter  prohibiting  them;  (3)  obesity  and  chronic  ne- 
phritis or  gout,  the  obesity  requiring  animal  food,  the  latter  none 
(unless  it  be  milk)  ;  (4)  acute  rheumatism  and  extreme  anaemia,  the 
former  requiring  no  solid  animal  food,  the  latter  demanding  it;  (5) 
ascites  and  chronic  nephritis,  where  the  quantity  of  fluid  ingested  as 
well  as  the  diet  may  present  opposite  requirements. 

When  such  complications  arise  it  is  possible  to  compromise  for  a 
time  upon  a  milk  diet,  this  being  the  most  natural  food,  and  one 
which,  on  the  whole,  is  capable  of  more  universal  adaptation  than 
any  other.  In  other  cases,  as,  for  example,  in  the  first  instance  men- 
tioned above  —  of  diabetes  accompanied  by  severe  Bright's  disease  — 
one  must  be  governed  by  the  patient's  general  condition,  the  gain  or 
loss  of  body  weight,  the  strength  of  pulse  and  muscle  tone  being  the 
important  guides  for  one  or  other  system  of  dieting.  The  lesser  evil, 
whichever  it  may  be,  must  give  place  to  the  greater,  and  a  gener- 
ous mixed  diet  may  sometimes  be  found  to  serve  the  patient  bet- 
ter than  one  too  much  restricted  by  theoretical  considerations. 

(1)  In  diabetes  with  chronic  nephritis,  foods  which  will  do  no  harm 
to  cither  are :  Egg?,  milk,  cream,  junket,  butter,  bacon,  squab  or 
chicken  (occasionally),  c'bee?e,  custards,  sweetbread,  tongue,  brains, 
tripe,  marrow,  fresh  fish  and  crustaceans  (occasionally),  oysters  and 


ASSOCIATED  DISEASES  771 

clams,  and  any  of  the  fresh  green  vegetables  allowed  diabetics,  as  listed 
on  page  744. 

(2)  In  chronic  gastric  catarrh  with  tuberculosis  and  extreme  lean- 
ness, predigested  cereal  foods  and  meats  may  be  tried,  with  eggs,  and 
diluted  cream.     Milk  sugar  will  sometimes  be  tolerated,  and  it  is  a 
good  tissue-sparer.     In  extreme  cases  one  or  two  nutrient  enemata 
may  be  given  daily  to  supplement  other  food. 

(3)  In  obesity  with  either  chronic  nephritis  or  gout,  if  the  symp- 
toms of  the  latter  diseases  are  not  urgent,  it  is  best  to  try  reduction 
treatment  for  the  obesity  for  about  a  month  or  six  weeks,  by  giving  a 
dry    proteid    diet    and    also    active    catharsis.     Then    the    reduction 
treatment  should  be  suspended  and  emphasis  may  be  given  to  treating 
the  albuminuria  or  gout.    In  either  one  of  these  conditions  foods  that 
will  not  prove  harmful  are  eggs  cooked  in  any  form,  and  any  of  the 
fresh   green  vegetables.     The   least   harmful   albuminoid    foods   are 
tongue,  sweetbread,  lean  ham,  squab,  chicken,  liver,  and  fresh  fish  of 
any  species. 

(4)  In  acute  rheumatism  with  extreme  anaemia,  it  is  essential  to 
treat  the  more  urgent  rheumatism  first  by  a  diet  of  milk,  bread  or 
crackers,  diluted  cream  and  junket.     Later,  as  acute  symptoms  subside, 
fresh  green  vegetables   (containing  salts  of  iron)   and  eggs  may  be 
given,  with  crisp  bacon  or  ham,  but  the  full  proteid  diet  for  anemia 
should  not  be  given  until  all  acute  symptoms  of  rheumatism  have  been 
absent  for  a  fortnight  or  more,  and  even  then  it  should  be  suspended 
every  three  weeks,  by  a  temporary  return  to  vegetarianism  until  re- 
covery is  assured. 

(o)  In  ascites  with  chronic  nephritis,  a  salt-free  and  dry  diet  (p. 
556)  should  be  tried,  and  the  reduction  of  fluids  desirable  for  ascites 
may  be  supplemented  by  diuretics  to  stimulate  the  kidneys. 

If  the  ascitic  fluid  can  be  drained  off  through  the  kidneys  to  any 
extent  (which  unfortunately  is  not  often  possible),  it  will  itself  serve 
as  a  diuretic,  and  the  ingestion  of  so  little  fluid  will  not  be  missed  by 
the  kidneys.  There  are,  however,  cases  in  which  a  milk  diet  proves  the 
best  compromise. 

The  foregoing  examples  serve  to  illustrate  the  principles  which 
should  govern  dietetic  treatment  in  the  many  complex  dietetic  prob- 
lems which  arise  from  association  of  different  diseases.  Each  case 
should  be  treated  according  to  the  balance  of  symptoms,  and  the  diet 
frequently  changed  as  they  may  vary.  Fixed  routine  in  such  conditions 
does  more  harm  than  good,  and  no  subject  taxes  the  skill  and  in- 
genuity of  the  dietist  more  than  the  treatment  of  such  complications, 
when  ordinary  rules  appear  contradictory. 


772  DIET  FOR  SURGICAL  PATIENTS 

DIET    FOE    SUKGICAL   PATIENTS,   DIET    IN   KELATION 
TO    OPEKATIONS,     ETC. 

FOOD  AND  ANESTHETICS 

Preparation  for  the  Administration  of  Anaesthetics. —  When  an 
anaesthetic,  such  as  ether  or  chloroform,  is  demanded,  care  should  be 
exercised  that  the  stomach  is  empty,  otherwise  vomiting  may  occur 
at  a  critical  moment.  Being  unconscious,  the  natural  reflexes  of  the 
process,  including  the  closure  of  the  epiglottis,  are  not  well  carried  out, 
and  food  is  readily  drawn  into  the  trachea  and  excites  serious,  if  not 
fatal,  choking.  For  this  reason,  when  time  permits,  the  patient  is 
usually  prepared  for  the  anaesthetic  by  giving  a  light  and  easily  di- 
gested breakfast,  consisting  solely  of  milk  with,  perhaps,  a  little  far- 
inaceous food,  or  a  cup  of  coffee  and  a  roll,  and  three  or  four  hours 
later  the  anaesthetic  may  be  administered  with  safety. 

Feeble  patients  sometimes  require  an  ounce  of  brandy  or  whisky 
half  an  hour  before  the  operation  —  long  enough  before  for  it  to 
become  absorbed. 

It  is  never  desirable  to  give  an  anaesthetic  within  four  hours  after 
ingestion  of  a  full  meal.  It  impedes  anesthetization,  besides  causing 
the  dangers  above  mentioned.  It  is  better  to  allow  six  or  more  hours 
to  intervene.  In  an  emergency  where  an  accident  occurring  shortly 
after  a  heavy  meal  requires  the  immediate  use  of  anaesthesia,  it  may 
be  well  to  give  an  emetic  first  for  the  purpose  of  completely  unloading 
the  stomach  before  the  patient  becomes  unconscious. 

The  instances  of  fatal  choking  from  vomiting  and  aspirating  food 
into  the  larynx  are  fortunately  rare,  as  they  are  preventable,  but  they 
are  by  no  means  unknown.  Since  their  occurrence  is  almost  always 
due  to  negligence  on  the  part  of  the  anaesthetizer  in  not  observing 
proper  precautions,  they  are  usually  inexcusable.  Ether  is  more  likely 
than  chloroform  to  prove  irritating  and  excite  vomiting  while  being 
inhaled.  When  retching  is  violent  it  sometimes  may  be  overcome  by 
"  crowding  "  the  anaesthetic  —  that  is,  by  causing  it  to  be  inhaled  more 
energetically  for  a  moment,  until  reflex  irritation  is  overcome.  In 
laparotomy  it  is  especially  desirable  to  have  the  stomach  and  intes- 
tines as  empty  of  food  and  gas  as  possible,  to  facilitate  exploration  of 
the  abdomen. 

Diet  After  Anaesthesia. —  Ether,  much  more  than  chloroform,  is 
liable  to  occasion  prolonged  nausea  and  vomiting  after  its  adminis- 
tration has  ceased,  and  this  may  last  in  very  susceptible  persons  for 
a  day  or  two.  In  all  cases  where  ether  is  employed  to  produce  pro- 


DIET  AFTER  SURGICAL  OPERATIONS  773 

found  narcosis,  even  when  only  used  to  assist  physical  examinations 
for  diagnostic  purposes,  it  is  well  that  caution  should  be  observed  for 
some  hours  afterwards  by  withholding  food,  and  thereafter  a  light 
fluid  diet  of  peptonized  milk,  beef  tea,  or  a  cup  of  cocoa,  tea,  or  coffee 
only  should  be  allowed  when  any  tendency  to  nausea  or  vomiting  exists. 
If  the  patient  has  been  much  exhausted  by  hemorrhage  during  the 
operation  or  by  prolonged  anesthesia,  nourishment  may  be  given  by 
the  rectum  (p.  455).  In  cases  of  laparotomy  for  operations  upon  any 
part  of  the  alimentary  canal,  such  as  appendicitis,  it  may  prove  best  to 
give  the  digestive  organs  physiological  rest  for  one  or  two  days,  but  if 
the  patient  is  in  need  of  nourishment  one  or  two  food  enemata  may  be 
administered. 

The  following  schedule  of  diet  for  the  day  may  be  taken  as  an 
example  for  a  minor  operation  under  anesthesia : 

7  A.  M. —  A  cup  of  beef  tea,  coffee,  or  cocoa,  or  a  cup  of  bread  and 
milk.  11  A.  M. —  Anaesthesia  and  operations.  5  p.  M. —  Iced  milk  and 
Vichy,  beef  essence,  or  peptonoids.  If  vomiting  occurs,  give  hot  water, 
or  half  an  ounce  of  brandy  with  soda.  9  P.  M. —  Bread  and  milk,  or 
beef  jelly,  or  cocoa  and  a  biscuit.  Nothing  more  until  the  next  day, 
when,  if  there  are  no  special  reasons  to  the  contrary  from  existing  dis- 
ease or  complications  arising  from  the  operation,  as  in  laparotomy,  the 
patient's  previous  customary  diet  may  be  resumed  gradually. 

DIET  AFTER  INJURIES  AND  SURGICAL  OPERATIONS 

Fractures,  wounds,  ulcers,  and  all  grave  surgical  injuries  naturally 
heal  the  sooner  the  better  the  condition  of  the  blood.  Abundant  nour- 
ishing diet,  properly  selected  in  regard  to  its  ready  digestibility,  is 
therefore  indicated.  Starvation  promptly  impoverishes  the  blood  and 
retards  all  healing  processes. 

Mild  Cases. —  In  feeding  surgical  patients  who  are  confined  to  bed, 
or  who,  from  the  nature  of  their  injuries,  are  unable  to  exercise,  care 
should  be  observed  that  the  channels  for  removal  of  waste  from  the 
body  do  not  become  clogged  and  inert.  In  the  zeal  to  promote  rapid 
healing  by  a  liberal  diet  it  is  quite  possible  to  overcharge  the  blood 
with  products  of  nutrition  and  defeat  the  object  in  view  by  burdening 
the  liver  and  other  organs,  and  inducing  "  biliousness." 

The  patient's  appetite  should  not  be  the  only  guide,  but  the  con- 
dition of  the  tongue,  the  stools,  and  urine  should  be  examined  to  in- 
sure proper  assimilation  of  all  the  food  taken.  In  the  absence  of  sep- 
sis, fever,  and  all  affections  of  the  alimentary  canal,  there  is  usually 
no  harm  in  allowing  the  full  diet  of  animal  and  vegetable  food  to  which 


774  DIET  FOR  SURGICAL  PATIENTS 

the  patient  is  normally  accustomed,  or,  if  the  appetite  fails,  consider- 
able variety  in  the  dietary  may  be  permitted  advantageously. 

If  there  has  been  no  loss  of  blood  and  no  severe  shock,  soon  after  an 
ordinary  aseptic  operation  is  over  the  patient  is  practically  as  well 
as  he  was  before  it  was  performed. 

Sir  Watson  Cheyne  says :  "  After  operations  performed  aseptically 
there  is  no  reduction  of  diet  even  for  a  few  days.  A  hospital  patient 
remains  on  full  diet,  and  a  private  patient  may  have  anything  he 
fancies,  provided  it  is  wholesome,  and  the  more  nutritious  the  food 
the  better."  In  fact,  after  opening  a  large  abscess  or  a  carious 
joint  the  appetite  may  soon  return  and  "hunger  becomes  the  chief 
trouble." 

As  a  rule  stimulants  are  necessary  if  the  appetite  be  keen,  but 
otherwise  beer  or  Burgundy  or  dilute  whisky  may  be  prescribed  in 
moderation  as  an  aliment,  to  be  taken  with  the  meals  only.  Hard 
drinkers  who  receive  grave  injuries,  such  as  serious  fractures,  fre- 
quently develop  delirium  tremens  in  the  course  of  a  few  days,  and 
this  may  occur  even  when  they  have  not  been  indulging  in  stimu- 
lants for  some  weeks  previously.  In  such  cases  it  may  become  nec- 
essary to  allow  a  little  alcoholic  stimulation  at  stated  intervals  between 
meals,  in  order  to  tide  them  over  an  emergency  which  threatens  an 
immediately  fatal  result,  trusting  to  reduce  the  quantity  as  delirium 
subsides. 

Critical  Cases. —  If  severe  pain  has  preceded  an  operation,  if  the 
operation  has  been  prolonged,  or  if  there  has  been  much  shock,  even 
under  ansesthesia,  the  diet  should  be  supervised  with  great  care. 
Pain  is  a  strong  depressant,  and  after  shock,  rest  and  stimulation  is 
usually  more  desirable  than  food.  Positive  harm  results  from  over- 
feeding. Black  coffee  is  very  serviceable  for  such  cases  or  whenever 
there  is  lack  of  nerve  energy,  and  it  may  be  appropriate  to  keep  the 
patient  for  three  or  four  days  upon  a  diet  of  milk  or  pancreatinized 
milk.  Broths,  meat  extracts,  and  beaten  eggs  may  be  added  when 
the  stomach  regains  its  tone.  If  nausea,  anorexia,  or  disgust  for 
food  exist,  or  if  there  be  much  distention  of  the  stomach,  it  is  unwise 
to  force  food  upon  the  patient.  It  is  better  to  utilize  the  rectum  in 
such  cases,  and  strong  coffee,  pancreatinized  milk,  egg  albumen,  and 
alcohol  are  given  in  enemata.  Opium  or  other  necessary  medication 
may  be  added. 

If  extensive  loss  of  blood  has  taken  place,  the  volume  of  fluid  should 
be  replaced  in  the  body  as  soon  as  possible,  and  liquid  food  is  needed, 
such  as  milk,  beef  broths,  peptonoids,  and  brandy  or  whisky,  if  the 
stomach  retains  them.  Salt-water  rectal  injections,  or  in  severe  cases 


DIET  IN  SURGICAL  INFLAMMATIONS  775 

hypodermic  injections  of  saline  solutions,  help  restore  the  lost  fluid 
to  the  blood  and  improve  vascular  tone. 


Laparotomy,  Ovariotomy,  Etc. 

After  all  operations  involving  opening  the  peritoneal  cavity  com- 
plete rest  of  the  stomach  is  necessary  for  twenty-four  hours,  and  not 
infrequently  for  two  or  three  days.  Food  and  stimulants  may  be  given 
by  enemata  (p.  455).  If  fed  per  os  by  the  second  or  third  day  not 
more  than  a  tablespoonful  of  pancreatinized  milk  or  milk  with  lime 
water  or  barley  water  should  be  allowed  once  in  two  or  three  hours. 
Later  the  quantity  may  be  increased,  the  intervals  diminished,  and 
beef  tea,  beef  peptonoids,  and  egg  albumen  added. 

In  these  cases  the  duration  of  anaesthesia  has  usually  been  pro- 
longed, and  shock  is  considerable.  The  danger  from  the  occurrence 
of  vomiting,  malfermentation  of  food,  and  flatulent  distention  of  the 
abdomen  is  far  worse  than  that  of  inanition  from  abstinence.  When 
time  permits  it  is  well  also  to  precede  the  operation  by  a  day  or  two 
of  dieting  in  order  to  lessen  the  bulk  of  intestinal  waste.  To  this 
end  the  diet  should,  when  possible,  consist  chiefly  of  lean  meat  and 
dry  toast,  vegetables,  cereals  and  especially  sweets  being  avoided. 

After  wounds  and  operations  affecting  the  stomach  or  intestines  no 
food  at  all  should  be  given  by  the  mouth.  Nothing  but  a  little  cracked 
ice  should  so  be  administered,  and  all  nourishment  should  be  supplied 
for  4  or  5  days  by  the  rectum.  The  return  to  mouth  feeding  should  be 
made  very  slowly  and  cautiously  by  at  first  giving  not  over  one  or 
two  tablespoonfuls  of  pancreatinized  milk  or  beef  juice  at  a  time. 

There  is  often  much  thirst  following  operations  involving  the 
peritoneum,  which  is  relieved  more  by  hot  fluids  than  by  ice,  which 
sometimes  irritates  the  throat  and  increases  the  desire  for  drink.  If 
there  is  danger  of  fluids  swallowed  exciting  emesis,  a  hot  salt-water 
enema  once  in  three  or  four  hours  will  alleviate  thirst  (p.  452). 

DIET  IN  SURGICAL  INFLAMMATIONS,  SEPSIS,  ETC. 

The  diet  in  surgical  inflammatory  conditions  was  reduced  originally 
to  a  minimum,  with  the  idea  that  the  healing  process  would  be  more 
sure  if  the  stimulating  influence  of  food  was  removed,  and  that  the 
inflammation,  like  an  infectious  fever,  should  be  "  starved  out."  The 
diet  absolue,  as  the  French  surgeons  of  the  first  half  of  the  last  cen- 
tury termed  it,  meant  virtual  starvation,  barley  water,  arrowroot 
water,  or  toast  water  being  all  that  was  allowed.  With  improve- 


776  DIET  FOR  SURGICAL  PATIENTS 

merit  in  feeding  fevers  came  a  change  in  the  diet  of  inflammatory  con- 
ditions, and  it  was  recognized  that  the  waste  of  tissue  material  and 
the  expenditure  of  force  in  the  evolution  of  heat  must  be  replenished 
by  nutritious  food.  No  one  to-day  starves  pneumonia,  nor  yet  does 
an  intense  local  inflammation  of  a  joint  demand  that  the  patient 
should  have  solid  meat  meals,  but  there  is  an  appropriate  mean  to  be 
observed  between  overfeeding  and  starvation.  Sepsis  is  not  avoided 
by  starving,  and  the  patient's  strength  should  rather  be  supported  by 
easily  assimilable  food.  In  acute  inflammatory  conditions  tissue 
waste  is  rapid  and  appetite  and  digestive  power  are  lessened. 

In  critical  cases  a  diet  of  milk,  diluted  by  one-third  or  one-half 
with  Vichy  or  Seltzer  water,  may  be  given,  four  ounces  every  hour 
and  a  half  or  six  ounces  every  two  hours.  Other  articles  should  be 
added,  such  as  expressed  beef  juice  or  beef  extracts  (p.  135).  These 
substances  at  first  may  be  given  alone,  and  then  added  to  strong  beef, 
mutton  or  chicken  broth.  Gruels  of  arrowroot  or  oatmeal,  raw  eggs 
alone,  or  beaten  and  added  to  sherry  or  brandy,  custard,  milk  pud- 
dings, and  beef  jelly  are  all  recommended. 

When  improvement  occurs,  a  light  convalescent  diet  may  be  pre- 
scribed, such  as  that  detailed  on  p.  472.  Acidulated  drinks,  sour  lem- 
onade, oatmeal  or  barley  water,  and  effervescing  waters  may  be  used  to 
alleviate  thirst. 

In  mild  cases,  and  in  the  early  stages  of  many  inflammations, 
alcohol  is  not  required,  but  if  at  any  time  the  pulse  becomes  feeble, 
the  tongue  grows  dry,  or  delirium  supervenes,  stimulants,  such  as 
whisky  or  brandy,  should  be  given.  Elderly  patients  and  those  who 
have  previously  been  reduced  by  wasting  diseases  require  earlier  stimu- 
lation in  the  form  both  of  meat  extracts  or  meat  juice  and  alcohol. 
From  four  to  six  ounces  of  liquor  may  be  prescribed  in  twenty-four 
hours,  according  to  its  effect  on  the  pulse.  In  the  milder  inflamma- 
tions, especially  those  of  tubercular  joints,  malt  liquors  may  be  of 
service.  A  good  strong  toddy  at  night  may  be  made  to  take  the  place 
of  opiates. 

Burns,  when  severe  and  extensive,  require  prompt  and  energetic 
stimulation.  In  such  cases  a  pint  of  brandy  may  be  given  in  twenty- 
four  hours. 

In  chronic  surgical  diseases,  attended  by  formation  of  pus,  fresh  green 
vegetables  and  fresh  fruits  are  serviceable,  both  for  their  antiscorbutic 
and  laxative  effect.  Lemonade,  oranges,  baked  apples,  or  stewed 
prunes  are  recommended.  Fats  also  are  needed  especially,  and  butter, 
cream,  olive  oil.  bacon,  or  cod-liver  oil  should  be  added  liberally  to  the 
diet  when  the  patient  is  able  to  digest  foods  of  this  class. 


PRESCRIBING  DIETARIES 

In  prescribing  dietaries  for  private  patients,  it  is  well  to  be  sys- 
tematic and  exact.  Patients  are  very  appreciative  of  attention  to  their 
gastronomic  needs,  and  in  all  important  diseases  modified  or  induced 
by  diet  it  is  desirable  to  make  out  a  full  list  not  only  of  foods  which 
may  be  eaten,  but  of  prohibited  foods.  In  order  to  save  time  in  office 
work,  after  trying  various  methods,  I  have  found  it  convenient,  ac- 
curate and  time-saving  to  furnish  patients  with  a  printed  card,  con- 
taining a  menu  of  the  ordinary  foods  arranged  in  two  major  groups, 
the  first  comprising  such  foods  as  are  most  often  desirable,  or  "  foods 
allowed/'  the  second  comprising  those  foods  which  experience  has 
shown  are  most  often  to  be  "  f orbidden."  In  a  given  case  it  is  easy 
to  erase  foods  on  either  list,  or  to  transfer  them  from  one  list  to  the 
other.  The  cards  are  printed  on  both  sides  to  economize  space,  and 
of  a  size  convenient  for  the  patient  to  carry  in  the  pocket.  As  this 
system  may  prove  convenient  to  others,  I  append  the  menu  herewith : 


Dietary  for Date . 

FOODS  ALLOWED. 


Purees;    Soups,        (Vegetable,  meat.) 

Shellfish:  Oysters,  clams,  scallops,   (stewed,  broiled  or  escalloped,  not 

fried),  (soft  parts  only).     Oyster  broth,  clam  broth. 

Fish:  Fresh   fish,    (boiled   or  broiled,  not  fried)    as;    bass,  blue- 

fish,  butterfish,  cod,  flounder,  haddock,  halibut,  mackerel, 
perch,  red  snapper,  shad,  shad  roe,  smelts,  sole,  weak  fish. 

Eggs:  Soft -cooked,  scrambled  or  poached  (not  hard  boiled). 

Cereals:  Stale  bread,  toast  (dry  milk),  Graham  bread,  pulled  bread, 

crackers,  Huntley  and  Palmer  wafers  and  biscuits,  zwie- 
back, shredded  wheat,  trisket,  oatmeal,  wheatena,  wheaten 
grits,  thin  ginger  snaps,  cornmeal,  (mush),  boiled  rice, 
puffed  rice,  farina,  corn  starch,  hominy,  sago,  tapioca, 
samp,  macaroni,  spaghetti  (without  cheese). 

52  777 


778 


DIETARIES,   RATIONS 


Butter.  Cream. 

Vegetables:  Artichokes     (French,    Jerusalem),    asparagus,    beet    tops, 

Brussels  sprouts,  butter  beans,  cauliflower,  celery  (raw, 
stewed),  egg  plant,  lettuce  (French  dressing),  Lima  beans, 
okra,  onions,  oyster  plant,  parsnips,  young  fresh  peas,  white 
potatoes  (baked,  mashed,  stewed),  rhubarb,  spinach, 
squash,  string  beans,  tomatoes. 

Bed   Meats:  Rare  roast  beef,  beaf steak,  chops,  mutton,  lamb  (sparingly, 

once  a  day  only), 

Poultry  and  Chicken,  capon,  turkey,  squab,   Guinea  fowl,   duck,  goose, 

Game:  quail,  partridge,  snipe,  grouse,  pheasant. 

Miscellaneous:         Sweetbread,  ham,  thin  crisp  bacon,  liver,  tongue. 

Desserts:  Rice  pudding,  bread  pudding,  junket,  custard,  baked  cus- 

tard, Bavarian  cream,  whipped  cream,  sponge  cake,  maca- 
roons, gelatine  foods,  as  plain  wine  or  lemon  jelly,  blanc- 
mange; ice  cream,  plain  vanilla. 

Fruits:  Oranges,     lemons,     grape     fruit,     pineapple    (juice    only) 

peaches,  plums,  stewed  prunes,  apples  ( raw,  baked,  stewed ) , 
cantaloupe,  bananas,  grapes,  olives. 

Beverages:  Tea,  coffee,  cocoa,  alkathrepta,  lemonade,  orangeade,  milk 

or  cream  with  Celestin  Vichy,  buttermilk,  ginger  ale,  apol- 
linaris,  koumyss,  matzol,  zoolak;  hot  water  with  Liebig's 
or  other  meat  extract;  Postum,  Poland  water,  White  Rock, 
Lithia.  water. 


FOODS  FORBIDDEN 
(Other  forbidden  foods  may  be  erased  from  above  list). 


Sweets  of  all  kinds,  as:  confectionery,  bonbons,  candy,  honey,  sugar,  cake, 
"  cakes,"  syrup,  molasses,  jams,  marmalades,  preserves. 

Pastry,  pies,  puddings,  corn  bread,  Boston  brown  bread,  muffins,  gingerbread, 
hot  bread,  patties. 

Eich  soups,  gravies,  sauces,  "  dressing  "  or  "  stuffing,"  hashes,  stews,  ragouts. 

Fried  food  of  all  kinds,  all  twice  cooked  or  "  made-over  "  dishes,  canned,  dried, 
smoked,  salted,  potted,  candied  and  preserved  food  of  every  kind.  Veal, 
pork,  sausage,  pate"  de  fois  gras,  corn  beef,  brains,  tripe,  kidneys,  marrow. 

Condiments  and  spices,  vinegar,  mustard,  pickles,  cheese,  mushrooms. 

Lobster,  crabs,  terrapin,  caviare,  herring,  salmon,  sardines,  chowder. 

New  Potatoes,  sweet  potatoes,  radishes,  cucumbers,  cabbage,  corn,  beets,  tur- 
nips, horseradish,  cranberries,  beans. 

Nuts,  raisins,  berries. 


GENERAL  RULES. 


1.  Eat  slowly:  masticate  thoroughly. 

2.  Have  meals  at  regular  hours. 

3.  Avoid  anxieties  or  business  cares  at  table. 

4.  Rest  for  half  an  hour  or  more  after  luncheon  and  dinner. 

5.  Do  not  eat  more  than  a  half-dozen  kinds  of  food  at  any  one  meal. 

6.  Do  not  eat  too  much. 

7.  Take  but  little  fluid  of  any  sort  with  meals,  but  do  not  fail  to  drink  a 
glassful  of  water  half  an  hour  before  and  two  hours  after  meals. 


ABMY   DIETS  779 

ARMY  AND  NAVY  DIETS 

The  food  furnished  to  soldiers  and  sailors,  both  in  time  of  peace 
and  war,  is  more  accurately  weighed  and  measured,  and  its  effects 
are  more  accurately  studied,  for  economic  reasons,  than  is  the  diet  of 
any  other  class  of  men,  not  excepting  hospital  patients.  While  seek- 
ing to  furnish  wholesome  variety  it  is  necessary  to  keep  the  quantity 
of  food  as  uniform  as  possible,  and  this  may  be  done  by  substitution  of 
articles  the  nutrient  value  of  which  is  closely  related;  thus  eggs  may 
occasionally  be  substituted  for  milk,  or  peas  or  beans  may  be  served 
for  a  change  instead  of  cereals. 

The  United  States  Army  Rations 

A  "  ration "  is  technically  the  total  quantity  of  food  issued  for 
one  man  for  twenty-four  hours  in  accordance  with  law,  and  not,  as 
often  supposed,  the  allowance  for  one  meal.  The  original  principles 
upon  which  military  rations  have  been  selected  are  thus  summarized 
by  Major  Charles  E.  Woodruff,  Surgeon,  U.  S.  A. : 

"  1.  Economy  is  essential. 

"  2.  The  food  must  be  the  product  of  the  country  at  large,  neither 
a  specially  prepared  article  nor  the  output  of  a  few  manufacturers. 

"  3.  The  articles  must  be  easily  preserved  in  all  climates  by  the 
most  ignorant  men. 

"  4.  The  articles  must  be  easily  transported  and  capable  of  the 
roughest  handling  during  transit. 

"  5.  The  ration  is  intended  for  the  strongest  and  most  robust  men 
in  the  nation. 

"  6.  It  must  be  approximate  to  the  food  used  by  the  nation  at 
large,  so  that  there  will  be  no  rapid  change  of  diet  on  enlistment  that 
would  impair  the  health. 

"  For  these  reasons  the  soldier's  ration  has  always  been  simple  and 
dry." 

Some  of  these  principles,  as  the  author  quoted  points  out,  are  radi- 
cally wrong.  It  is  false  economy  to  furnish  too  cheap  or  monotonous 
diet,  which  only  courts  disease  and  swells  the  pension  roll. 

After  the  Revolutionary  War,  in  1785,  the  army  ration  consisted 
of  one  pound  of  beef,  one  pound  of  bread,  and  one  gill  of  rum.  This 
was  quite  insufficient,  and  was  subsequently  increased  (Woodruff). 
During  that  war,  in  addition  to  the  above  ration,  the  soldier  received 
one  pint  of  milk,  a  little  molasses,  and  a  few  dried  vegetables,  with  a 
quart  of  beer  in  place  of  rum. 

The  German  soldier  is  expected  to  eke  out  his  peace  ration  by  sup- 


780 


DIETARIES,   RATIONS 


plies  contributed  from  his  home,  and  the  French  and  English  soldier 
by  contributions  from  his  pay,  but  in  the  United  States  the  men 
usually  serve  so  far  from  home  that  this  system  is  neither  economical 
nor  desirable.  Moreover,  with  the  improvements  in  canning  and 
other  methods  of  food  preservation  and  condensation,  it  is  no  longer 
necessary  for  the  ration  to  be  the  product  of  the  surrounding  country. 
The  importance  of  an  adjustable  army  ration  is  appreciated  when  it 
is  considered  that  within  the  limits  of  service  in  the  territory  owned 
by  the  United  States  may  be  found  a  temperature  range  of  150°  F. 
Diet  suitable  for  Alaska  is  radically  unfit  for  Manila. 

UNITED  STATES  ARMY  RATIONS 
1.  For  Troops  in  Garrison 


STANDARD   ARTICLE  S. 

SUBSTITUTIVE  ARTICLES. 

Kinds. 

Quantities. 

Kinds. 

Quantities. 

Meat  components 
Bread         compo- 

Fresh  beef    .  . 
Flour  

20   ounces  .  . 

18    ounces.. 
2§   ounces  .  . 

16  ounces.  - 

Ig   ounce... 

Ig  ounce... 
3i    ounces  .  . 

f  Fresh  mutton  

20  oz. 
12  oz. 
16  oz. 
14  oz. 
18  oz. 
16  oz. 

18    02. 

16  oz. 
20  oz. 
2g  oz. 
Ig  oz. 
Ig  oz. 
12|  oz. 
3J  oz. 
12f  oz. 
34  oz. 
lli  oz. 

4f  oz. 
2g  oz. 

Ig  oz. 
Ig  oz. 

Ij75  OZ. 

&  oz. 

£  *!!• 

A  g111- 

j   Bacon     

J  Canned   meat    

1  Dried  fish    

j  Pickled   fish    

[  Canned   fish    

f  Soft   bread    

•{  Hard  bread   

Vegetable      com- 
ponents      

Dried    (or  evapo- 
rated)       fruit 
components    .  . 

Coffee  and  sugar 
components    .  . 

Seasoning  compo- 
nents           .    .  . 

Beans          ... 

(  Cornmeal     

r  Peas    

j  Rice    

.  Potatoes    .... 

(_  Hominy    

f  Potatoes     

(^  Onions      

f  Potatoes     

I  Canned  tomatoes   .  . 
f  Potatoes     

<!  Fresh        vegetables, 
not  canned    

Desiccated  vegetables 
f  Apples    

-j  Prunes     

I 
f  Coffee,   green  . 

Susiar 

1  Peaches  

f  Roasted  and  ground 
\  Tea,  black  or  green 

f  Vinegar    

J  Salt    

!25     6111  

if   ounce. 

^5-  ounce. 
^|   ounce. 
-fa  ounce. 

\  Cucumber  pickles  .  . 

[  Pepper,    black 
(  Soap 

Soap   and   candle 
components    .  . 

|  Candles    

781 


2.  For  Troops  in  the  Field  in  Active  Campaign 


STANDARD  ARTICLES. 

SUBSTITUTIVE  ARTICLES 

Kinds. 

Quantities 

Kinds 

Quanti- 
ties. 

Meat  components 

Bread         compo- 
nents    

Fresh   beef    .  .  . 
["  Flour    

20    ounces  .  . 
18    ounces.  . 

£f  ounce. 

2§    ounces., 
f 

16  ounces,  -j 

I 
If  ounce    .  . 

Ij75  ounce   . 
3J  ounces. 
8    CT;ii 

C  Fresh  mutton   

20  oz. 

16   02. 

12  oz. 
18  oz. 
16  oz. 
sV  oz. 

zV  oz. 
Ig  oz. 
12$  oz. 
34'  oz. 
2§  oz. 
Iff  oz. 
«oz. 
Iff  oz. 
34  oz. 

zs  oz. 

A  gill- 
z45  gill- 

•j  Canned  meat  

[  Bacon   

f  Soft  bread     

1  Baking    powder 
(Beans    

\  Hard  bread   

f  Hops   . 

-{  Dried  or  compressed 
yeast  

Vegetable       corn- 

Rice      

Potatoes    

f  Potatoes  

\  Onions    

Fruit    component 

Coffee  and  sugar 
components    .  . 

Seasoning      com- 

Desiccated    potatoes 
/  Desiccated    potatoes 
1  Desiccated  onions  .  . 
f  Desiccated    potatoes 
\  Canned  tomatoes   .  . 

Tea,  black  or  green. 
/  Vinegar    

Jam     

f  Coffee,    roasted 
and  ground  .  . 
[  Sugar  

-j  Salt    

Z5  Sm  

if  ounce. 
2J5  ounce. 
|f  ounce. 
7j6y  ounce. 

\  Cucumber  pickles  .  . 

Soap  and  candle 
components    .  . 

I  Pepper,    black  . 
f  Soap  . 

\  Candles    

5.  For  Troops  ichen  Traveling  otherwise  than  by  Marching  or  when  for  Short 
Periods  they  are  separated  from  Cooking  Facilities  (Travel  Ration) 


STANDARD  ARTICLES. 


Kinds. 

Quantities  per 
100  rations. 

Kinds. 

Quantities  per 
100  rations. 

Soft  bread    

112J  pounds.  . 

Hard  bread   

100  pounds 

Canned  corned  beef  

75    pounds.  . 

Corned  beef  hash 

75  pounds 

Baked  beans         

25    pounds. 

Canned  tomatoes   

50    pounds. 

Coffee,  roasted  and  ground 
Sugar  

8    pounds  . 
15    pounds. 

SCBST1TUTIVE  ARTICLES. 


"The  above    (3)    has  the  following  composition    (approximately)  : 


Protein 

Fats. 

Carbo 
hydrates 

Calories. 

(  Maximum 

150 

170 

417 

3,900 

Grams,  j  Minimum    

120 

94 

380 

2,900 

Alean                       

135 

132 

400 

3,400 

782  DIETARIES,  RATIONS 

"  This  ration  is  insufficient  for  active  men,  being  equivalent  to  the 
food  of  men  of  sedentary  habits.  The  protein  is  the  only  ingredient 
in  nearly  the  proper  amount,  and  this  arises  from  the  meats  and 
beans"  (Woodruff). 

For  the  tropics  this  ration  contains  twice  too  much  salt  pork  and 
fresh  meat  and  too  few  fresh  vegetables.  The  white  beans  especially 
cause  diarrhoea,  and  the  canned  tomatoes  are  liable  to  ferment.  The 
tropical  red  beans  are  less  irritating  than  the  domestic  white  beans. 
Red  beans  and  hominy  are  the  staple  of  the  Mexican  army  diet 
(Seaman). 

Although  considerable  latitude  is  allowed  in  the  use  of  substitute 
foods  or  variants  in  the  diet,  in  actual  practice  army  officials  and  cooks 
commonly  follow  routine  methods.  In  commenting  upon  the  impor- 
tance of  adapting  our  army  ration  to  the  needs  of  the  tropics,  Major 
Kean  states : 

"  Fish  is  largely  eaten  by  all  tropical  races  near  the  source  of  sup- 
ply, and  is  undoubtedly  less  stimulating  and  more  easily  digested  than 
butcher's  meats.  For  this  cause,  and  to  secure  variety,  fresh  fish, 
where  obtainable,  should  be  used  twice  a  week,  no  savings  being 
permitted. 

"  The  issue  of  the  meat  components  at  Columbia  Barracks,  Cuba, 
for  185  consecutive  days  in  1900  was  as  follows: 

Fresh  beef  124  days. 

Mutton  .. none. 

Bacon    47  days. 

Fresh  fish 1  day. 

Other  issues 13 


"  \Vhich  shows  well  the  monotony  of  the  issue,  the  only  impor- 
tant variant  being  the  undesirable  bacon.  A  certainly  more  desirable 
issue,  and  one  apparently  permissible  according  to  the  paper  ration, 
would  have  been,  for  example,  somewhat  as  follows : 


Fresh  beef  100 

Fresh  mutton   37  davs. 

Fresh  fish    38  days. 

Other  issues 10  days. 

"A  saving  of  two-fifths  of  the  fresh  meat  being  authorized.  As 
fresh  fish  is  quite  cheap  at  Havana,  the  difference  in  cost  would  have 
been  immaterial." 

Major  Kean  states  (U.  S.  Surgeon  General's  Report  for  1900)  that: 
"  A  tropical  dietary,  as  compared  with  one  suited  to  a  colder  climate, 
should  have  less  fat  and  more  carbohydrates,  less  stimulating  proteids 


ARMY   DIETS 


783 


in  the  form  of  meat,  a  greater  variety  of  diet  both  of  meats  and  of 
carbohydrates  in  the  form  of  fresh  vegetables  and  fruits,  and,  lastly, 
a  fairly  liberal  supply  of  ice."  His  argument  for  the  substitution  of 
carbohydrates  for  fats  is  that  the  digestion  is  weakened  in  hot  climates 
and  the  liver  is  inclined  to  torpidity,  while  ingested  fats  are  prone  to 
split  up  into  butyric,  caproic,  and  other  irritating  acids,  which  the 
diminished  secretion  of  the  liver  is  unable  to  neutralize. 


Kean's  Proposed  Tropical  Ration. 


ARTICLES. 

Quantities 
per  ration 
(ounces). 

Saving  au- 
thorized 
(ounces). 

Meat  components: 
Fresh  beef                

20 

8 

or  fresh  mutton                       .          

20 

8 

or  fresh  fish              

20 

None. 

or  when  these  cannot  be  furnished 
Bacon                 

12 

12 

or  salt  beef                                   ...                

12 

12 

or  dried  fish   

14 

14 

or  pickled  fish          

18 

18 

or  canned  salmon    

16 

16 

(Mutton  and  fish  tc  be  issued  each  twice  in  ten  days.) 

Bread  components: 
Same  as  present  ration. 

Vegetable  components: 
Rice           .          

2a 

Frijoles             

if 

or  macaroni  

31 

Jfone 

Fresh   vegetables  in  proper  variety    (purchased   in  the 
vicinity  of  the  post  when  practicable)    

16 

Ice  

32 

Coffee,  sugar  and  seasoning  components: 
Same  as  present  ration. 

Munson,  in  an  essay  which  was  awarded  the  prize  of  the  Military 
Service  Institute,  for  a  tropical  ration,  states :  "  It  is  true  that  the 
sugars  and  starches  should  be  slightly  augmented,  but  their  increase  is 
small  when  compared  with  the- considerable  reduction  of  nitrogenous 
and  fatty  matter  which  is  proposed." 

When  leading  a  comparatively  inactive  garrison  life  the  ration  may 
prove  too  large  —  i.  e.,  the  food  furnishes  more  energy  than  the  body 
needs,  but  there  is  not  always  enough  variety.  Any  excess  of  food  is 
then  sold  to  a  co-operative  store,  and  the  money  thus  acquired  is  ex- 
pended for  a  few  luxuries  to  stimulate  the  appetite. 

The  usual  army-ration  tables  are  misleading  in  that  they  omit  to 


784 


DIETARIES,   RATIONS 


account  for  the  consumption  of  such  accessory  food,  which  is  pur- 
chased by  the  soldier  in  addition  to  the  portion  he  receives  as  fixed  by 
law.  Major  Woodruff  has  computed  the  nutrient  value  of  the  entire 
food  eaten  by  the  men  of  the  garrison  at  Fort  Assiniboine,  Montana, 
during  a  period  of  ten  days.  His  table  follows : 

Uncooked    Food    of    Garrison    Ration    for    Ten    Days.     Weights   in    Pounds. 
Daily  'Average,  440-4  Men  (Woodruff) 


Gross 
weight. 

Waste. 

Net 
weight. 

Water. 

Pro- 
tein. 

Fats. 

Carbo- 
hydrates. 

Salts. 

Calories. 

Bacon  

vrv/4 

428M 
343^ 
781 
4,879 
5,025 
5,116 
700 
44 
85 
10 
188 

89 
58 
165 
107^ 
26 
63 
332 

52^ 
81 
81 

IOM 

85 

250 
82 
20 
5 

4^ 

8K 

270 

428^ 

my4 

731 
4,252^ 
8,894 
8,730 
550 
44 
85 
10 
188 

39 
58 
165 
107M 
26 
63 
332 

52^ 
31 
81 
10 
15 

200 
28 
20 
5 

& 

8 

54.00 
54.05 
87.85 
21.98 
531.56 
2,196.70 
2,943  00 
481.80 
3.34 
12.75 
8.82 
46.85 

0.78 
6.09 
70.60 
12.90 
3.22 
51.22 
318.72 

6.88 
25.61 
7.75 
8.50 
10.00 

182.00 
11.63 
13.50 

21.60 
99.10 

2.82 

187.65 
8.57 
259.00 

6.75 
18.29 
18.14 
3.66 
21.26 
35.95 
37.30 
3.80 
0.88 
1.19 
0.03 
2.57 

0.08 
1.74 
8.80 
4.30 
0.14 
0.88 
1.00 

0.42 
0.31 
0.93 
0.50 
0.25 

2.20 
0.76 
0.12 
0.15 
0.12 
0.08 
0.12 

831,600 
691,228 
1,097,753 
1,312,081 
6,991,110 
5  409,392 
1  398,750 
123,750 
81,400 
139,825 
3,150 
259,494 

70,980 
209,670 
168,795 
383,775 
42,380 
21,735 
26,560 

78,815 
12,552 
49,442 
16,000 
3,500 

81,000 
54,880 
9,200 
9,000 
7,043 
6,153 
7.950 

Beans  

253.80 

Pork  

81 

Sugar,  brown  

705.42 
3,185.12 

'667.67 
55.55 
30.01 
60.01 
1.59 
130.85 

88.14 
0.29 
90.60 

Flour  

126^ 
1,181 
1,386 
150 

"J 

50 
4 

467.78 
682.97 
78.83 
7.70 
6.65 
7.82 
0.02 
1.65 

46.78 
978.38 
8.78 
1.65 
3.13 
8.23 
0.04 
3.30 

Beef  

Potatoes  

Onions  

Oatmeal  

Cornmeal  

Apples  canned.... 

Apples  dried  

Tapioca    and    Corn- 
starch  

Butter  

0.58 

49.30 

Lard  

0.65 
1.92 
1.77 
2.66 

4.73 
1.58 
5.27 
3.30 
0.75 

4.20 
4.68 
0.40 
0.65 
1.20 
0.05 
0.60 

89.66 
0.14 
0.70 
1.38 

0.15 

1.50 
8.41 
2.20 

Rice  

20.65 

8.32 
8.30 

40.32 
2.00 
13.64 
0.50 
4.00 

11.00 

Tomatoes,  canned.  .. 
Macaroni    and    Ver- 
micelli    

Milk  fresh  Ibs  

Milk,  condensed,  Ibs. 

Cabbage   and   sauer- 

0.60 
11.00 

6.00 
3.80 
2.54 
3.50 
0.30 

0.14 
0.08 

Peas          

0.55 
6.45 
0.48 

14 
3 

4 

1.50 

Totals  ... 

18,598 

2,9083* 

15.(iS9k/ 

7,120.50 

1,413.21 

1,657.17 

5.343.66 

154.82.19.446.960 

Pounds. 

Grains. 

Daily   average    per 

4  22 

3.56 

0.66 

738 

145 

171 

550 

16 

4  416 

Counting     flour     as 

S5^% 

15«% 

bread,    amount 

eaten  is  4  Ibs.  per 

man.     Per  cent  cf 

45 

9 

11 

34 

1 

ARMY   DIETS 
Additional  Articles  consumed 


785 


Daily  per 
man. 

Allowance. 

338  Ib.  green  coffee  
8  Ib    tea    

1.23    oz. 
0.03    oz. 

0.14    gill 
0.46  oz. 

0.036  oz. 

l.GOoz.  or 
0.32    oz. 

0.32    gill 
0.64    oz. 

0.04    oz. 

f  Allowance   is   large,   to   al- 
low of  making  a  saving 
•<        to    be    used    in    making 
sauerkraut     and     pickles 
in  the  fall. 

20  gal    vinegar       .. 

128   Ib.   salt    

10  Ib.  pepner  . 

1 1       bottles      flavouring 
extracts. 

3  Ib.  mustard. 

24  Ib.  baking  powder. 
6  Ib.  currants. 
5   gall,   pickles. 

4  kegs  pickled  pigs'  feet. 


f  Though  containing  much  energy,  it  is  omitted  be- 
•<  cause  composition  is  unknown,  and  the  actual 
[_  amount  per  man  is  very  small. 


It  is  well  known  that  the  history  of  prolonged  wars  has  presented 
a  far  greater  death  rate  from  disease  than  from  the  wounds  of  battle, 
and  much  of  the  former  is  caused  by  improper  or  insufficient  food, 
which  induces  dysentery,  diarrhoeas,  anemia,  and  gastritis  and  reduces 
resisting  power  against  other  diseases. 

EMERGENCY   RATIONS 

For  scouting  parties,  troops  under  forced  marching,  or  under  any 
circumstances  which  makes  the  supply  of  the  ordinary  ration  impos- 
sible, an  emergency  ration  for  temporary  service  is  necessary. 

The  most  concentrated  ration  which  is  practicable  for  soldiers  to 
carry  in  the  field  consists  of  bacon,  hard-tack,  and  coffee.  This  is  a 
scorbutic  diet,  and  always  produces  constipation,  to  obviate  which  it  is 
now  customary  to  carry  desiccated  fruits,  concentrated  by  drying, 
and  which  are  not  spoiled  by  extremes  of  temperature. 

In  the  autumn  of  1900  an  emergency  ration  was  tested  in  Idaho 
upon  a  troop  of  cavalry.  The  ration,  packed  in  an  elliptical  can  eight 
inches  long,  weighed  one  pound  and  contained  three  cakes  of  sweet 
chocolate  (four  ounces),  three  of  a  meat(  four  ounces),  and  grain 
compound  (eight  ounces),  having  a  taste  not  unlike  parched  corn. 
The  latter  may  be  eaten  uncooked,  or  as  porridge  or  fried  mush. 
Salt  and  pepper  accompanies  the  cakes.  The  food  may  be  eaten 
dry,  as  a  soup  or  porridge,  or  fried.  The  test  proved  successful.  The 
details  of  preparation  of  this  ration,  furnished  me  by  General  Alfred 
A.  Woodhull,  U.  S.  A.,  are  as  follows : 


786 


DIETARIES,   RATIONS 


The  chocolate  component  consists  of  equal  weights  of  pure  choco- 
late and  pure  sugar  molded  into  cakes  of  one  and  one-third  ounces 
each.  Three  of  these  compose  the  day's  ration. 

The  bread  and  meat  component  consists  of  :  (1)  Fresh  lean  beef 
free  from  visible  fat  and  sinew,  ground  in  a  meat-grinder  and  desic- 
cated so  as  to  contain  five  per  cent  or  less  of  moisture,  the  heat  never 
being  allowed  to  cook  it  in  the  slightest  degree.  The  dried  product 
is  then  reduced  to  powder  and  carefully  sifted  through  a  fine-meshed 
sieve,  the  resulting  flour  being  the  meat  component. 

(2)  Cooked  kiln-dried  wheat,  the  outer  bran  removed,  is  parched 
and  then  ground  to  a  coarse  powder.  This  yields  the  bread  com- 
ponent. Sixteen  parts  of  the  meat,  thirty-two  parts  of  the  bread, 
and  one  part  of  common  salt,  all  by  weight,  are  thoroughly  mixed  in 
such  small  quantities  as  to  be  entirely  homogeneous  and  compressed 
into  four-ounce  cakes.  Three  of  these  compose  the  day's  ration.  The 
bread  and  meat  may  be  eaten  dry,  or  stirred  in  cold  water;  or  one 
cake  may  be  boiled  for  five  minutes  in  three  pints  of  water  and  sea- 
soned to  taste ;  or  one  cake  may  be  boiled  for  five  minutes  in  one  pint 
of  water  to  make  a  thick  porridge  and  be  eaten  hot  or  cold.  When 
cold  it  may  be  sliced,  and  if  fat  is  available  may  be  fried. 

Three-fourths  of  an  ounce  of  fine  salt  and  15^  grains  of  black 
pepper  are  in  the  can  for  seasoning. 

"  This  ration  is  calculated  to  subsist  a  man  for  one  day,  maintain- 
ing his  full  strength  and  vigor/'  As  it  amounts  to  a  pound  of  water- 
free  food  it  may  serve  its  purpose  if  not  depended  upon  too  long. 

Foreign  Army  Rations 

Soldiers'  Daily  Peace  Ration,  in  Ounces  Avoirdupois 


British 

(average). 

French. 

Austrian. 

German. 

Bread  

24  0 

35.2 

31.0 

26.50 

Meat    (uncooked)    ... 

12.0 

10.6 

9.87 

8.81 
3.80 

(larger  ration) 
(smaller  ration) 

It  is  apparent  from  this  table  that  the  French,  Austrian,  and  Ger- 
man rations  all  contain  more  bread  and  less  meat  than  the  English. 
In  addition,  the  men  have  potatoes  and  other  vegetables,  green  or 
dried,  besides  sugar,  coffee,  salt,  etc.,  which  are  issued  either  with 
the  ration  or  purchased  with  a  special  allowance  of  pay,  so  that  the 
above  figures,  which  apply  to  only  two  articles,  fall  somewhat  short 


ARMY  DIETS 

of  the  actual  food  consumed.  For  example :  The  British  soldier  re- 
ceives a  total  of  sixty-five  ounces  of  solid  food  against  the  French 
soldier's  fifty-one  ounces ;  but  many  of  them  are  undergrown  men,  be- 
ing several  years  under  twenty-five,  up  to  which  the  period  of  forma- 
tion of  the  bones  is  not  always  complete.  The  British  army  ration 
contains  from  four  to  six  ounces  less  meat  than  the  United  States 
ration,  and  4.2  ounces  more  rice. 

In  England  the  daily  ration  of  the  soldier  on  home  service  con- 
sists of  one  pound  of  bread  (twenty-four  ounces  is  given  above  as  the 
average  for  foreign  service),  an  ounce  and  a  fifth  of  sugar,  and  three- 
quarters  of  a  pound  of  meat,  which  is  supplemented  by  an  allowance 
of  about  fivepence  a  day  to  be  expended  on  minor  articles  of  diet, 
green  vegetables,  milk,  and  beverages. 

In  the  French  army  legumes  form  an  important  element  of  the 
ration,  to  some  extent  replacing  animal  food,  and  many  experiments 
have  been  made  with  the  German  army  in  regard  to  the  introduction 
of  vegetable  food,  especially  pea  meal,  which  is  rich  in  protein. 

In  France  and  Holland  during  active  service  in  the  field,  in 
maneuvers,  or  in  battle,  the  diet  is  materially  increased.  Experiments 
made  upon  an  Austrian  regiment  in  garrison  showed  an  average  gain 
in  weight  of  6.6  pounds  per  man  in  three  months  upon  a  steady  daily 
allowance  of  protein  120  grams,  fat  56  grams,  carbohydrates  500 
grams. 

The  larger  ration  of  the  German  army,  issued  during  the  marches 
or  maneuvers,  contains  about  five  ounces  more  meat  than  the  garrison 
ration,  and  several  ounces  more  vegetable  food,  and  in  war  thirteen 
ounces  of  meat  are  given.  Bacon,  salt  meat,  and  rice  are  also  sup- 
plied. 

The  German  army  ration  for  the  tropics  contains  5.33  ounces 
of  fresh  meat,  or  44  ounces  of  bacon  and  seventy-nine  ounces  of 
vegetables.  Chocolate  has  been  added  to  the  emergency  ration  in 
both  Germany  and  Austria. 

All  the  largest  armies  of  Continental  Europe  issue  a  wine  ration  in 
war  times. 

To  the  French  war  ration  are  added  nine  ounces  of  wine  or  two  and 
a  quarter  ounces  of  brandy  per  diem. 

Munson  advocates  the  use  of  a  tropical  army  ration  comprising 
fresh  fruit,  soft  bread,  potatoes,  rice,  tomatoes,  dried  fruits,  sugar, 
and  protein  limited  to  one  hundred  grains  (3  ounces). 

The  following  comparative  table  of  various  national  army  rations 
was  published  by  Major  Charles  E.  Woodruff,  M.  D.,  U.  S.  A.,  in  the 
New  York  Medical  Eecord  (vol.  Iv,  No.  20). 


788 


DIETARIES,  RATIONS 


ARMY  RATIONS  OF  VARIOUS  NATIONS 


NATION. 

RATION. 

Protein. 

to 

a 

Carbohy 
drates. 

Calories. 

REMARKS. 

Cms. 

Cms, 

Cms. 

This    is    starvation 

diet,  and  the  ex- 

1. England  . 

1.  Home    

93 

61 

244 

1,938 

tra    food    needed 
for       health,       is 
purchased        and 
charged      against 

2.  Foreign  station,  or 
under    canvas    at 

home         

111 

80 

244 

2,175 

the   soldier  (about 

120 

80 

327 

2,550 

six  cents  a  day), 

increasing,      per- 

haps,     doubling, 

J        the  food  value. 

f  Max. 
4.  War   .        .  .  •{   Hi- 

165 
133 

128 
92 

425 
425 

3,634 
3,204 

)    Can       be       greatly 
>        changed     to    suit 
)       climate. 

\  Mm. 

Sometimes     2     oz. 

rum    

175 

Sufficient    for    such 

2.  Spain    .  . 

1.  Peace     {  \fi*' 

147 
120 

87 
62 

588 
500 

3,729 
3,421 

a     mild     climate 
and   very   moder- 
ate  work. 

2.  War,         on  f  Max. 
march  or  in-| 

131 

94 

522 

3,327 

}  Varies       enormous- 
ly   according    to 
class    of    rations 

the       field  I  Min. 

113 

55 

485 

2,550 

issued.            Very 

Sometimes    1.7    oz. 
brandy    

150 

many     extra     al- 
lowances of  mon- 
ey for  food. 

•v    This    is    augmented 

by  four  cents  per 

day    for    vegeta- 

bles, etc.      On  the 

march    a    limited 

emergency   ration, 

3.  Austria  . 

1.  Peace    

155 

125 

504 

3,865 

is       used.       The 

2.  War    

165 

130 

504 

3,952 

war  ration  is   so 

insufficient      that 
commanders        of 

armies   or   small- 

er     forces      may 

change,       supple- 

ment,     or      even. 

'        double   it. 

Allowances    of   one- 

fifth  cent  per  day 

for      condiments; 

4.  Italy    .  .  . 

1.  Garrison     

111 
115 
125 

130 
133 
143 

600 
600 
600 

4,129 
4,163 
4,307 
250 

occasional     extra 
money           allow- 
ances   for    food. 
Excepting         the 
protein,    it    is    a 

2.  Camp    

3.  Marching   

Usually  wine  added. 

very    liberal    diet 

for    such    a    mild 

J        country. 

789 


NATION. 

RATION. 

Protein. 

tn 

a 

Carbohy- 
drates. 

Calories. 

REMARKS. 

Cms 

Cms 

Cms 

1   This    is    what     the 

government     may 

5.  Germany 

1.  Small       ra-  ] 

supply.       Usually 

tions      and 

the   soldier   feeds 

portions  in  [  Max 
garrison        [   Min. 

150 
99 

40 
40 

703 
502 

3,947 
2,827 

himself     and      is 
I      given  seven  cents 
a    day,    or   more, 

and       can-  | 

to           reimburse 

tonments     J 

himself.          Food 
eaten      is      more 

than     this     defi- 

cient diet. 

2.  Large       ra-  ~) 

tions     and  |  M 
portions  on  1-  vlax 
march  or  in  1  Min" 

172 
138 

62 
57 

915 
644 

4,961 
3,744 

manoeuvres  J 

3.  Field             j  Max. 

195 

151 

703 

4,786 

\  Mm. 

78 

75 

515 

3,413 

Commanding     gen- 

eral  may   add    3J 
oz.  whisky  

268 

6.  United 
States 

1.  By  law   .  ..  |^x' 

2.  Usually     in  f  Max. 
field       (byJ   Min. 

183 
105 
106 
64 

260 
103 
320 
240 

621 
500 
540 
460 

5,368 
3,712 
5,166 
4,722 

Maxima       due       to 
fats  if  all  the  ba- 
con  is   used   and 
no       meat.      The 
whole    ration    is 
supposed     to    be 

law)     [  Ave. 

85 

280 

500 

5,000 

supplied           and 
eaten. 

3.  Food        actually  " 

eaten     in     cold 

climate,   moder- 

ate    work,     in- 
cluding  all    ex- 

155 

180 

597 

4,907 

^ras    from    gar- 

dens   and    pur- 

chases       J 

-    Peace     *ation     not 

stated.     It  is  pur- 

chased   as    need- 

ed   and    charged 

against       soldier. 

War    .           ..•%•»!•' 

183 

300 

690 

5,455 

War      ration      is 
subject    to    great 

/  .  Jr  rmicc     • 

\  Mm. 
Add  2T\y  oz.  brandy 

146 

127 

520 

4,015 
184 

augmentation    for 
increased       work 

or    cold    climate. 

The    commanding 

officer     can     aug- 

ment   ration    on 

the   march. 

Also    allowed    mon- 

ey   to    buy    one- 

half    to    one    and 

8.  Russia    . 

•    -r.                     f  Min. 
1.  Peace     .  .  .  .\  Max 

233 

165 

114 
65 

976 
746 

5,884 
4,450 

one-half      ounces 
extra    meat,    and 

Add  3  oz.  wine   .  . 

223 

one    to    one    and 
one-half         cents 

for        vegetables, 

salt,  butter,  lard, 

and    groceries. 

o    TTT                    f  Max. 
!.  War           .  .  <  -Kf 

174 

62 

805 

4,583 

Extra      meat      and 
)       spirits     may     be 

\  Mm. 

149 

50 

640 

3,307 

J.       ordered     by     the 

Add  4J  oz.  wine 

362 

\       commander         in 

'       chief. 

790 


DIETARIES,   RATIONS 


As  stated  by  Major  Woodruff,  the  United  States  is  the  only  nation 
in  the  world  that  in  time  of  peace  pretends  to  supply  the  entire 
ration.  Soldiers  living  in  densely  populated  European  countries 
supplement  their  rations  by  local  purchases  from  a  mess  fund  or,  as 
in  Germany,  from  supplies  from  home.  In  Austria  bread  alone  is 
furnished  as  a  peace  ration,  other  food  being  purchased  from  a  money 
allowance.  At  remote  frontier  posts  in  the  United  States  a  variety 
of  local  purchases  is  frequently  unobtainable,  and  hence  the  attempt 
to  supply  the  whole  ration  in  kind. 

United  States  Navy  Rations 

Table  showing  the  different  U.  8.  "Navy  Rations  and  their  Component  Parts, 
as  established  by  Law,  with  the  Substitutes  legally  alloiced  for  each 
Article. 

ALLOWANCE  FOB  GENERAL  USE 


RATIONS  AS  COMPOSED 
BY  LAW. 

EITHER  OF  THE  FOLLOWING— 

Specified  by  law. 

Substitutes  authorised  by  law. 

Ration  No.  1    .... 
Ration  No  2  

1    Ib.   salt   pork. 
J    pt.    beans    or   peas. 

1    Ib.    salt   beef. 
J  Ib.  flour. 
2    oz.    dried    fruit. 
2    Ib.   preserved   meat. 
J  Ib.  rice 
2  oz.  butter. 
1  oz.  desiccated  mixed  vege- 
tables. 
|   Ib.   preserved  meat. 
2  oz.  butter. 
6  oz.  desiccated  tomatoes. 

1J  Ib.  fresh  meat,  or 
2  Ib.  preserved  meat. 
Vegetables  of  equal  value,  or 
i   Ib.  rice. 
1J  Ib.   fresh   meat,  or 
2  Ib.  preserved  meat. 
Vegetables  of  equal  value. 
No   substitute. 
|  pt.  beans  or  peas. 
No   substitute. 
6  oz.  canned  vegetables. 

No  substitute. 
No  substitute. 
6  oz.  canned  tomatoes. 

Ration  No.  3  

Ration  No.  4  

WEEKLY  ALLOWANCE 


J  pt.  pickles, 
i  pt.  molasses. 
J  pt.  vinegar. 

DAILY  ALLOWANCE 


14  oz.  biscuit. 

i  oz.  tea. 
4  oz.  sugar. 


1  Ib.  soft  bread. 
1   Ib.   flour. 

1  Ib.  rice. 

2  oz.  coffee. 
2  oz.  cocoa. 

For  coffee  and  sugar,  extract 
of  coffee  combined  with  milk 
and  sugar  may  be  substi- 
tuted by  the  Secretary  of  the 
Navy,  if  not  more  expensive. 


NAVY  DIETS  791 

The  law  allows  one  of  the  above  complete  rations  to  be  used  on 
any  or  each  day  of  the  week,  or  they  each  may  be  used  in  turn  as 
convenient,  in  case  it  becomes  necessary  to  vary  the  order  prescribed 
elsewhere.  (Estimated  average  cost  per  capita  per  diem,  thirty 
cents.) 

The  following  statement  is  from  the  New  York  Medical  Eecord: 
"  The  naval  full-diet  table  is  as  follows  for  one  day  in  the  week, 
the  number  after  each  article  relating  to  ounces:  Breakfast  —  cof- 
fee, 1 ;  bread,  4 ;  butter,  1 ;  milk,  6 ;  sugar,  1 ;  oatmeal,  1 ;  beefsteak,  6. 
Dinner  —  rice  soup,  8 ;  bread,  4 ;  roast  beef  or  roast  or  boiled  fowl,  8 ; 
potatoes,  8;  other  vegetables,  6;  pickles,  1;  bread  pudding  with 
sauce,  6;  or  custard  frozen,  8;  fresh  fruit,  6.  Supper  —  tea,  14 ; 
bread,  6 ;  butter,  1 ;  milk,  2 ;  sugar,  1 ;  cold  roast  mutton  or  cold  roast 
beef,  4 ;  stewed  dried  fruit  or  baked  fresh  fruit  or  apple  sauce,  4.  The 
staples  —  coffee,  bread,  butter,  milk,  sugar,  and  fresh  and  dried  fruit 
—  are  the  same  for  each  meal,  but  there  is  a  daily  variety  in  meats 
and  other  articles  for  breakfast,  dinner,  and  supper.  The  proportions 
are  about  the  same,  however,  especially  in  the  matter  of  meats,  as 
in  the  specimen  diet  table  given  above.  In  addition  to  its  use  for 
convalescents,  the  table  is  now  observed  for  all  naval-hospital  em- 
ployees, and  is  gradually  becoming  the  standard  aboard  ship  and  in 
the  marine  corps.  Its  adoption  was  the  result  of  most  patient  and 
thorough  investigation  by  Surgeon  I.  D.  Gatewood,  who  consulted 
all  the  leading  authorities  on  the  subject." 

Table  showing  the  Quantities  of  the  Different  Articles  of  the   U.  S.  Navy 
Ration  which  are  required  for  One  Man  for  One  Year 

Biscuit  3191  pounds. 

Biscuit   ( with  flour)    182 

Cornmeal   52 

Oatmeal   52 

Rye  flour  or  hominy  52          " 

Wheat  flour    52 

Salt  pork 104 

Beans   6|  gallons. 

Peas    31 

Salt  beef  52     pounds. 

Rice 26 

Dried  fruit   13 

Butter 19J        " 

Tomatoes     19J        " 

Canned   meal    78 

Ham  or  bacon    39 

Sausage  or  salt  fish   39  " 

Coffee 26 

Tea    4| 

Cocoa    19J         " 

Sugar 91J        " 

Pickles     26  " 

Molasses    31  gallons. 

Vinegar     3-J        " 

Canned   vegetables    39     pounds. 


792 


DIETARIES,   RATIONS 


The  British  Navy  ration  contains  one  pound  of  fresh  meat,  one 
pound  and  a  half  of  bread,  or  one  pound  and  a  quarter  of  sea  biscuit. 

In  comparing  navy  with  army  rations  it  should  be  remembered 
that  on  shipboard  a  proper  cooking  range,  utensils,  and  fuel  are  al- 
ways obtainable,  whereas  entirely  different  conditions  obtain  with  an 
army  in  the  field. 

Table  showing  the  Different  Articles  of  the  U.  8.  T$avy  Ration,  for  which 
Practical  Equivalents  or  Substitutes  are  permitted,  with  the  Quantity  of 
each  allowed  for  Issue. 


ARTICLES  NAMED  IN 

THE  LAW. 

Articles  considered  as  included  under  names  given 
in  preceding  column. 

Quantity  allowed 
per  ration. 

/  Biscuit    

14  oz. 
1  Ib. 

As    substitute 
for      1      Ib. 
bread. 

12  oz. 

2  oz. 

J  oz. 
2  oz. 

U  Ib. 

U  Ib. 
6  oz. 

Bread  
Flour   

1  Soft  bread   .  . 

C  Cornmeal    .  .  . 

.  .  "1 

Corn  (hominy 
K  Oatmeal    .... 

I 

Preserved  meat   .  . 
Dried  fruit  

Rye    

f 

Wheat   

I 

f  Roast  beef   .  . 

.     } 

Canned  muttoi 
Chicago  cornec 
Brawn     

[  beef  

Ham    

Bacon    

. 

Sausage    .... 

(  Dried 
Fish  \  Smoked 
I           (  Pickled 
f  Dried  apples.  " 
Peaches. 
Raisins. 
-{  Currants. 
Prunes. 
Figs. 
[  Dates. 

I  May  be  substii 

C  Beef.          ] 
Mutton. 
J.    Veal.            1U 
Pork. 
I  Poultry.     J 
f  Fresh    (such  a 
1  Canned   (assor 

Or   any   other   kind   of  \ 

Tea                

uted  for  each  other  > 
r  any  other  kind  of  fresh 

Cocoa          ' 

Fresh  Meat  

Vegetables  

s  can  be  procured  )          ... 

ted  kinds  )    

DIET  IN  PRISONS 

In  prisons,  penitentiaries,  or  reformatories  the  diet  should  be 
adapted  to  keep  the  patients  in  good  health  through  periods  of  years, 
while  it  is  maintained  at  a  minimum  of  expense  to  the  community. 
A  brief  review  of  such  established  diets  is  useful  in  furnishing  an 
idea  of  quantity  and  quality  of  food  required  to  fulfil  the  necessary 
conditions. 


DIET    IN  PEISONS  793 

Voit  calculated  that  for  a  prisoner  not  engaged  in  hard  labor  the 
following  diet  is  sufficient  to  maintain  health :  Carbohydrates,  three 
hundred  grams ;  albumin,  eighty-five  grams ;  fat,  thirty  grams/  or  a 
proportion  of  about  10,  3.5,  and  1. 

In  some  penal  institutions  the  inmates  are  placed  upon  a  progressive 
diet  —  that  is,  a  diet  which  is  regulated  according  to  the  duration  of 
their  sentence,  the  degree  of  labor  exacted  from  them,  and  their  con- 
duct. Such  a  diet  has  been  recommended  by  the  British  Commis- 
sioners of  Prisons,  graded  for:  (1)  Periods  of  seven  days  or  less. 
(2)  Periods  between  seven  days  and  one  month.  (3)  Periods  be- 
tween one  and  four  months.  (4)  Periods  exceeding  four  months. 

A  somewhat  similar  system  is  detailed  below  —  that  of  the  United 
States  Army  Prison  at  Fort  Leavenworth. 

Diets  of  the  United  States  Army  Prison,  Fort  Leavenworth, 

Kansas 

General  Diet. —  Breakfast. —  Hash,  on  Tuesday,  Wednesday, 
Thursday,  Saturday  and  Sunday.  Mutton  or  beef  stew,  on  Monday 
and  Friday.  Coffee,  one  quart  each  morning. 

Dinner. —  Pork,  one  day  each  week.  Corned  beef,  one  day  each 
week.  Eoast  beef  and  gravy,  three  days  each  week.  Boiled  beef  and 
gravy,  two  days  each  week.  Vegetable  soup,  daily  except  Sunday. 

One  pint  of  coffee  each  Sunday.  Pork  may  be  substituted  for 
^corned  beef  or  boiled  beef  one  day  each  week  during  cold  weather. 

To  the  above  will  be  added  pickled  cucumbers,  beets,  or  toma- 
toes on  alternate  days,  and  such  other  vegetables  as  may  be  available 
from  the  prison  farm. 

Supper. —  Tea  or  coffee,  one  quart;  bread,  as  much  as  required. 
Stewed  apples  or  prunes  on  alternate  days. 

Diet  No.  1. —  The  following  diet,  known  as  "  Solitary,"  is  given  pris- 
oners confined  in  cells  for  punishment,  while  not  performing  any 
labor : 

Breakfast. —  Bread,  eight  ounces,  water  ad  libitum. 

Dinner. —  Bread,  eight  ounces;  water  ad  libitum. 

This  punishment  is  given  only  for  short  periods,  varying  up  to 
twenty  days. 

Total  farinaceous  foods,  sixteen  ounces. 

Diet  No.  2. —  The  following  diet,  known  as  "  Restricted,"  is  given 
prisoners  confined  in  cells  for  punishment,  while  not  performing  any 
labor : 

Breakfast. —  Hash  or  stew,  eight  ounces.  Bread,  seven  and  a  half 
ounces. 


794  DIETARIES,   RATIONS 

Dinner. —  Soup,  eight  ounces.  Bread,  seven  and  a  half  ounces. 
Salt  ad  libitum. 

Supper. —  Bread,  eight  ounces. 

The  eight  ounces  of  bread  for  supper  to  be  given  after  the  twenty 
days  of  subsistence  on  the  previous  diet. 

Total  proteid  food,  eight  ounces;  total  farinaceous  food,  twenty- 
three  ounces. 

Diet  No.  3. —  The  following  diet  is  given  to  prisoners  who  have 
undergone  punishment: 

Breakfast. —  Hash  or  stew,  ten  ounces.  Bread,  ten  ounces.  Cof- 
fee and  sugar  in  the  usual  amounts. 

Dinner. —  Soup,  the  usual  amount.  Beef,  eight  ounces,  or  pork, 
six  ounces.  Peas  or  beans,  six  ounces,  or  hominy  in  the  usual  amount, 
or  potatoes,  eight  ounces.  No  other  vegetables  except  such  as  are 
contained  in  the  soup. 

Supper. —  Bread,  ten  ounces.     Tea  and  sugar  in  the  usual  amounts. 

To  prisoners  who  have  been  on  "  Eestricted  Diet "  for  more  than 
ten  days  and  less  than  twenty  days,  or  on  "  Solitary  Diet "  for  ten 
days,  the  above  diet  (No.  3)  is  given  for  two  days. 

For  those  who  have  been  on  "  Eestricted  Diet "  for  twenty  days  or 
more,  or  on  "  Solitary  Diet"  for  fifteen  days,  the  above  diet  (Xo.  3) 
is  given  for  three  days. 

At  a  Conference  of  the  Prison  Association  of  New  York,  the  follow- 
ing bill  of  iare  was  recommended  for  general  adoption  in  prisons. 
The  quantity  of  food  is  not  specified : 

Sunday 

"Breakfast. —  Pea  soup,  bread  and  butter. 
Dinner. —  Baked  beans',  brown  bread,   pudding. 
Supper. —  Bread  or  crackers,  cheese,  milk. 

Monday 

Breakfast. —  Oatmeal  or  boiled  rice,  with  sugar  and  milk. 
Dinner. —  Salt  fish,  vegetables,  fruit. 
Supper. —  Bread  and  butter,  milk. 

Tuesday 

Breakfast. —  Bean  porridge,  bread. 

Dinner. —  Roast  beef,  two  or  more  kinds  of  vegetables,  bread. 
Clipper. —  Bread  and  milk,  molasses. 

Wednesday 

Breakfast. —  Pea  soup,  bread. 

Dinner. —  Beef  or  mutton  stew,  with  vegetables.  (Rice  may  be  used  in 
place  of  potatoes.) 

Supper. —  Cornmeal  mush,  molasses. 

Thursday 

Breakfast. —  Bread   and   butter,   milk. 
Dinner. —  Baked  beans,  bread,  fruit. 
Supper. —  Bread  and  butter,  cereal,  coffee. 


THE   SKIMMED    MILK   CURE 


795 


Friday 

Breakfast. —  Pea  soup,  bread. 

Dinner. —  Fresh  fish,  vegetables.      ( Rice  may  be  used  in  place  of  potatoes. ) 
Supper. —  Bread  and  milk,  cheese. 

Saturday 

Breakfast. —  Oatmeal  mush,  milk,  bread. 
Dinner. —  Corned  beef,  vegetables. 
Supper. —  Bread  and  milk,  molasses. 

The  dietary  of  the  New  York  State  Beformatory  follows  in  tabular 
form  on  pages  796-798. 

The  comparison  of  this  Beformatory  Diet  with  other  standard 
rations  is  presented  in  the  following  table  of  actual  nutrient  values: 


NUTRIENTS,  IN  GRAMS. 

Protential 
energy, 
in  calories. 

Pro- 
tein. 

Fats. 

Carbo- 
hydrates. 

Reformatory  standard  dietary  daily  ration  *    

119 
167 
154 
154 

119 
118 
85 
105 

61 
75 
69 
69 

51 
56 
30 
40 

556 
810 
794 
776 

531 
500 
300 
500 

3,334 
4,696 
4,524 
4,452 

3,140 
3,050 
1,857 
2,852 

Actual  upper  first  grade  ration   

Actual  lower  first  grade  ration   

Actual   second   grade   ration    

Playfair's  standard  for  adults,  moderate  exercise  .  . 
Voit's  standard  for  labouring  men  at  moderate  work 
Voit's  standard  for  prisoners  in  idleness  

Voit's  standard  for  prisoners  at  work  

THE  SKIMMED  MILK  CURF 

The  milk  "  cure  "  does  not  apply  to  the  temporary  exclusive  milk 
diet  of  typhoid  fever  and  similar  acute  febrile  conditions,  but  it  is 
bel  \eved  by  its  advocates  that  this  food  not  only  counteracts  certain 
abnormal  conditions  and  meets  definite  requirements  of  the  body, 
but  that  the  exclusive  milk  diet  possesses  a  special  curative  value  in 
some  classes  of  cases.  Bauer  says  emphatically :  "  It  is  an  indisput- 
able fact  that  in  certain  diseases  a  methodical  use  of  the  milk  cure 
gives  results  such  as  can  be  attained  by  no  other  treatment." 

It  has  been  carried  out  successfully  by  Pecholier,  "Weir  Mitchell, 
Karell,  and  others  for  the  treatment  of  obstinate  chronic  intestinal 
disorders,  especially  enteralgia,  intestinal  dyspepsia  and  colitis;  in 
chronic  congestion,  hypertrophy,  and  fatty  degeneration  of  the  liver; 
in  asthma,  pulmonary  catarrh,  and  emphysema;  in  dropsies  of  renal, 

*  All  food  supplies  are  issued  according  to  this  standard  dietary,  except 
bread,  which  is  unlimited.  The  average  consumption  of  bread  per  man  is 
somewhat  in  excess  of  one  and  one-half  ration  per  meal,  thus  accounting  for 
the  increase  in  value  of  the  actual  ration  over  that  of  the  standard  dietary, 
which  conforms  very  nearly  in  food  values  to  the  standards  of  Voit  and  Play- 
fair. 


796 


DIETARIES,   RATIONS 


I 

4 
< 

[^  >•• 

''•=8 

'     § 

u 

QO  GO  *4|  1O  Clp  t*  A                Ct                00  O)  CX  -f  CO  t~ 

eoeDcocSNSS            2            B     2s          3 

S 

J,}BUI 

COt*00        O  Cb                JO                CDOcDO-^t 

'UIW 

KB 

ooo      —  —            o           oetenfto 

«> 

. 

'•    •    •      SN"           «           £^§-«§ 

us 

<n 

il 

•z 

:  j  :  :°clS        -        «ocoo~,2 

eo  2     » 

3 

. 

M  g[ 

•     •     •     •  O  kO  ^H               O               ?O  ^H  ^f«  o  •*  O 

H 

-= 

:   :   :   :»12®          »          t2§fe!=p:§ 

Q 

H 
2 

re 

c 

o*--HOoeeo           o           ooooo    • 

ION        w 

£ 

o  i-  «  o  o  cs  N           ot           ^^-Hia-*    . 

Iff 

^SSiSt;^0           °"          -t-Neio    • 

O 

H 

,j 

B9c5e99cS         55         S35S-: 

§?5     » 

A 

0 

1-1  •*  e*  o  o  •>*  ^           o           oocxoo    • 

S"    a 

. 

2 

OOO^HOOOOSOO           o           -"--NIO-*    • 

& 

k* 

£ 

c- 

O^-t-Ct«-^TO»H                CM                —  ^  U3  CO  O  t—     » 

OOCBiO       t-O               O               cot-t-O-rf 

H 

y 

« 

CO  -^  T             COCO                CO                            ^-  ^H  ^* 

W 

t-H 

Q 

Refuse. 

D    G    y 

D  * 

• 

CR  O  O            O               O 

i* 

3-' 

§388888S888g§88Sc5{28 

K5-* 

CO  84 

O 
H 

II 

O 

.goo-«88«*^^-o.«o2o-- 

I" 

< 

& 

•» 

M 

S 

•o 

oo             oo^^w^^     ^ 

o 

re 
tfl 

- 

00  CO^ 

* 

^ 

• 

CO 

• 

t> 

<o             co                        XX 

£ 

- 

CO 

H 

w    . 

• 

oo 

•o 

-H          CO                                                                          CO 

r^ 

S 

H 

- 

"•                         OOCC 

S  . 

BO 

CO 

S 

Q 

C  X 

•o  re 

•B 

co         co^Xe.XXX    ^ 

o 

j 

- 

OOCDiR 

•* 

Q 

re 

'• 

00 

^ 

a 

M 

T3 

O 

•O 

«o             eo^X—  X         iR^S^ 

00 

B 

w 

a 

H 

- 

CD 

00  CO 

^ 

»; 

« 

CO 

a 

72 

TJ 

"8 

W                   CON                                     J£ 

CO 

S 

- 

00                                                      Tf 

^ 

« 

CO 

• 

•a 

C 

•O 

e»  oo 

"o         "° 

&  ^        CB 

W 

* 

CD 
COCO 

?-O       t3 
»  „.        B 

C  e        ' 

o  o    55 

-Q           •      -   3      

•s  jjsillijiMj  jiMi 

I" 

U«l£^ffl^OHCJ(£«Hlofflfflt|| 

THE   SKIMMED  •  MILK   CURE 


797 


;s 

•  -T 
*-       I      -•*' 


xi          iff  in 
o          ce  -t 


85' 


.-I      I     CON 


S     S? 


o-i- 

-a 


O5O 


8      § 


i« 

s-a 
1  = 

O  o 


u 

o  i  « 

—  o  o 

1 


882 


is 


is   is 


is 


is   is 


iss 

S  :c 


i-8 

o  o 

c  c 
o  o 


S3382S 


XX 


xx 


XX    X 


*-a 

o  o 


1  2  =£?.=• 
UcnQucou 


798 


DIETARIES,   RATIONS 


From  the  New   York  State  Reformatory  Annual  Report 

Calculations   based   on    Prof.    Atwater's   tables,    with    Reformatory   standard 

diet  added. 


COMPARISON  OF  DAILY  DIETARIES 


Carbohydrates 


Fats 


Protein         Potential  energy 


Nutrients,  Grammes- 


Potential  Energy,  Calories, 


Subsistence  diet  (Playfair) 

Under-fed  labourers,  Lombardy,  Italy 

Students,  Japan 

Lawyers,  Munich,  Germany 

Well-paid  mechanic,  Munich,  Germany 

Well-fed  blacksmith,  England 

German  soldiers,  peace  footing 

German  soldiers,  war  footing 

French-Canadian  families,  Canada 

Mechanics  and  factory  operatives,  Massachusetts 

Well-to-do  family,  Connecticut 

College  students,  Northern  and  Eastern  States 

Machinists,  Boston,  Mass 

Hard-worked  teamsters,  etc. ,  Boston,  Mass 

U.  S.  Army  ration 

U.  S.  Navy  ration 

N.  Y.  State  Reformatory  standard 

Reformatory  standard  daily  ration 

Actual  upper  first  grade  dietary 

Actual  lower  first  grade  dietary 

Actual  second  grade  dietary 

Play  fair's  standard  for  adults,  moderate  exercise 

Voit's  standard  for  labouring  men  at  moderate  work 

Volt's  standard  for  prisoners  in  idleness 

Voit's  standard  for  prisoners  at  work 


THE  SKIMMED   MILK  CURE  799 

cardiac,  and  hepatic  origin ;  in  hysteria  and  hypochondriasis,  in  which 
the  predominant  symptoms  are  dyspepsia  and  malnutrition;  and  in 
chronic  catarrhal  conditions  of  the  whole  alimentary  canal. 

The  milk  cure  also  is  recommended  in  cases  of  neurasthenia, 
obesity,  rheumatism,  gout,  chronic  valvular  cardiac  diseases,  and 
chronic  Bright's  disease. 

Dosage  and  Method  of  Giving  the  Milk. —  The  milk  used  is 
skimmed,  and  it  is  important  to  have  it  obtained  as  fresh  as  possible. 
It  is  customary  to  begin  with  comparatively  small  doses  —  about  four 
ounces  once  in  two  hours  throughout  the  day,  with  one  or  two  doses 
at  night.  At  the  end  of  a  few  days  the  dosage  may  be  increased  to 
six  or  eight  ounces,  and  the  intervals  made  three-hourly,  and  finally 
four-hourly,  when  twelve  tumblerfuls  are  given  daily.  When  the 
treatment  is  undertaken  it  should  be  carried  out  with  absolute  regu- 
larity and  system,  both  as  regards  the  quantity  of  milk  consumed  and 
the  intervals  at  which  it  is  given;  otherwise,  if  too  large  quantity  is 
drunk  at  one  time,  or  the  intervals  are  too  frequent,  undigested  milk 
remains  in  the  stomach  to  mingle  with  the  fresh  doses,  and  abnormal 
fermentation  and  dyspeptic  symptoms  result.  It  is  much  better  that 
the  milk  should  be  given  alone  whenever  large  quantities  are  to  be 
taken  for  a  long  time.  The  milk  usually  is  prescribed  either  luke- 
warm or  cold,  except  where  diarrhoea  exists,  when  it  may  be  boiled 
if  the  patient  so  prefers  it,  but  this  is  not  necessary.  Should  indiges- 
tion occur  during  the  first  week,  as  a  rule,  the  alimentary  canal  later 
becomes  accustomed  to  the  diet,  digestion  proceeds  actively  and  nutri- 
tion improves. 

Further  suggestions  will  be  found  under  the  heading  of  the  article 
on  the  Adaptation  of  Milk  for  the  Sick  (p.  84).  Not  a  few  patients 
learn  to  prefer  the  milk  to  more  highly  seasoned  food.  If  the  patient 
choose  —  and  it  is  wholly  a  matter  of  taste  —  the  milk  may  be  fla- 
vored with  very  weak  tea,  weak  coffee,  or  caramel,  and  a  pinch  of 
sa'lt  should  be  added  to  each  tumblerful.  Exceptionally  the  flavor  of 
a  little  spice  of  some  sort  may  be  preferred.  Some  patients  tolerate 
the  diet  better  if  the  milk  is  diluted  by  one-third  or  one-half  with 
some  alkaline  table  water,  lime  water,  or  Vichy,  or  it  may  be  scalded 
with  a  little  boiled  water  to  which  five  grains  of  sodium  bicarbonate 
and  three  or  four  grains  of  common  salt  are  added.  Milk  from  thor- 
oughbred cows,  especially  Alderneys,  is  often  too  rich,  and  it  is  unde- 
sirable to  give  much  cream.  Skimming  the  milk  is  therefore  necessary 
in  such  instances,  and  sometimes,  even  after  the  milk  is  skimmed, 
it  is  better  digested  if  diluted. 

In  carrying  out  this  treatment  much   depends  upon  having  the 


800  DIETARIES,   RATIONS 

patient  understand  the  theory  of  the  cure,  so  that  his  willing  co- 
operation may  be  obtained  in  a  method  which  is  monotonous  and 
wearisome  at  best.  The  main  object  of  the  treatment  is  to  enable  the 
digestive  organs  to  rest  and  recuperate  when  they  are  in  an  exhausted 
or  irritable  condition  by  giving  only  small  quantities  of  this  ele- 
mentary food  at  first.  Later,  as  digestion  improves,  larger  quantities 
are  tolerated  and  the  strength  and  nutrition  of  the  patient  will  be 
promoted  by  increasing  the  dosage  to  whatever  maximum  can  be 
reached  without  taxing  the  stomach. 

Symptoms  Accompanying  the  Treatment. —  The  pulse  at  first  is 
accelerated  and  arterial  tension  is  lowered.  There  may  be  muscular 
prostration.  The  frequent  occurrence  of  constipation  is  an  indication 
that  the  milk  is  being  well  digested  and  absorbed,  leaving  small  resi- 
due. Diarrhoea  or  obstinate  vomiting,  on  the  other  hand,  indicate 
indigestion  and  malnutrition,  and  the  difficulty  should  be  corrected 
by  temporarily  reducing  the  quantity  of  milk  and  prolonging  the  in- 
tervals between  the  doses  to  four  or  six  hours.  Constipation  is 
met  by  the  use  of  a  pill  or  two  grains  of  inspissated  oxgall,  by  the 
compound  licorice  powder  (pulvis  glycyrrhizae  compositus),  a  dose  of 
rhubarb,  half  an  ounce  of  castor  oil,  or  thirty  to  sixty  minims  of 
fluid  extract  of  cascara.  The  addition  of  coffee  to  the  milk  drunk 
in  the  earlier  hours  of  the  day  sometimes  renders  it  laxative,  and,  if 
necessary,  prunes  or  stewed  or  baked  apples  may  be  taken  once  daily, 
in  the  middle  of  the  afternoon. 

In  addition  to  the  milk,  patients  should  be  allowed  water  or  aerated 
waters.  It  is  well  that  water  should  be  given  although  thirst  be 
not  complained  of.  After  a  fortnight  or  three  weeks  some  patients 
complain  very  much  of  the  absence  of  solid  f ood^  and  in  such  cases  — 
if  the  digestion  is  favorable  —  stale  bread,  crackers,  dry  toast,  or  a 
little  salt  fish,  as  Dutch  herring,  may  be  allowed,  or  a  milk  soup  thick- 
ened with  barley  or  groats.  Some  patients  do  well  to  take  one  of  the 
prepared  foods,  such  as  are  in  familiar  use  for  infant  feeding,  like 
granum  or  malted  cereals,  p.  188.  As  a  usual  result  of  the  treat- 
ment, patients  lose  weight  during  the  first  ten  days  or  two  weeks,  but 
after  the  quantity  of  milk  begins  to  be  increased  they  may  gain  con- 
siderable weight  and  strength,  excepting  in  the  case  of  very  obese  per- 
sons, who  may  continue  to  lose  fat  after  the  maximum  dosage  of  milk 
has  been  attained.  Drowsiness  is  also  a  common  symptom  in  the 
first  few  days.  The  tongue  is  covered  with  a  white  or  yellowish  coat- 
ing, and  there  is  often  a  disagreeable,  mawkish  taste  in  the  mouth. 
The  latter  condition  may  be  relieved  very  largely  by  proper  care  (see 
Treatment  of  Typhoid  Fever,  p.  482).  The  urine  is  increased  in 


THE   WHEY   CURE  801 

quantity  and  of  low  specific  gravity.  The  increase  possibly  is  due  to 
the  large  amount  of  lactose,  which  is  somewhat  diuretic  in  action ;  but 
when  given  alone,  I  have  not  found  it  to  possess  exceptional  power. 
According  to  Weir  Mitchell,  the  uric  acid  is  greatly  reduced,  the  color 
of  the  urine  is  of  a  somewhat  pale  greenish  hue,  and  indol  and  skatol 
disappear.  He  calls  attention  to  the  extensive  changes  in  assimila- 
tion in  the  body  which  these  various  alterations  in  excretions  indicate. 
(See  Urine  and  Food,  p.  543.) 

After  about  six  weeks  of  milk  diet  the  substitution  of  solid  food  is 
to  be  made  gradually,  reducing  the  number  of  milk  meals  by  at  first 
one  a  day  for  a  day  or  two,  then  by  two,  and  so  on  until  all  food  is 
taken  solid,  and  Karell  suggests  that  lean  raw  scraped  beef  with  stale 
bread  is  the  best  to  begin  with.  The  diet  should  be  so  graded  as  to 
consist  largely  of  milk  for  several  months. 

THE  WHEY  CURE 

The  whey  cure  is  extensively  practiced  in  the  mountainous  regions 
of  Germany  and  Switzerland  and  at  various  springs  or  baths,  especially 
those  of  the  alkaline  waters,  which  latter  are  frequently  mingled  with 
the  whey  and  drunk  either  warm  or  cold.  The  treatment  is  rigorous, 
and  consists  in  confining  the  patient's  diet  largely  to  the  use  of  about 
twenty  ounces  per  diem  of  fresh  milk  whey.  The  principles  of  the 
treatment  are  essentially  similar  to  those  of  the  milk  cure,  but  in  whey 
the  casein  of  the  milk  has  been  artificially  removed  to  make  cheese  by 
the  addition  of  rennet,  the  milk-curdling  ferment. 

The  composition  of  whey  is  given  on  page  119. 

The  whey  cure  is  used  for  the  treatment  of  Bright's  disease  and 
chronic  catarrhal  conditions  of  the  alimentary  canal.  It  is  partic- 
ularly recommended  for  chronic  dyspepsia  and  chronic  irritable  cough 
accompanying  catarrh  of  the  respiratory  mucous  membranes. 

It  is  said  to  improve  the  bronchial  secretion  in  chronic  bronchitis. 
If  more  than  twenty  ounces  are  ingested  daily  there  is  increased  peri- 
staltic movement,  with  watery  evacuations,  colic,  and  dyspepsia. 

Whey,  like  skimmed  milk,  is  diuretic  and  sudorific.  It  therefore 
constitutes  a  useful  beverage  in  fevers.  The  class  of  patients,  many 
of  them  phthisical,  for  whom  the  cure  is  recommended  at  Ems,  Ischl, 
Eeichenhall,  etc.,  are  not  fit  subjects  for  a  continued  reducing  diet,  as 
they  have  little  or  no  spare  strength;  they  require  rather  abundant 
nourishment,  owing  to  the  catarrhal  processes  which  affect  the  re- 
spiratory and  alimentary  passages.  However,  in  such  cases  diges- 
tion and  absorption  are  often  greatly  impaired,  and  this  condition  is 
5G 


802  DIETARIES,   RATIONS 

found  to  be  benefited  by  the  use  for  a  short  period  of  the  alkaline 
waters  and  whey.  It  is  not  safe  to  limit  the  diet  exclusively  to  these 
fluids,  as  it  is  limited  in  the  skimmed  milk  cure  (p.  795),  and  some 
proteid  food  should  be  given,  together  with  fresh  fruit  and  green  veg- 
etables. In  Switzerland  and  Germany  the  whey  cure  is  often  com- 
bined with  the  grape  cure. 

THE  "  KOUMISS  CURE  " 

The  "  koumiss  cure  "  consists  in  taking  a  large  quantity  of  koumiss 
in  combination  with  nourishing  albuminous  food.  If  perfectly  fresh 
it  may  be  drunk  warm,  but  if  it  is  to  be  kept  for  some  time  it  is  better 
to  drink  it  cold.  Koumiss  which  is  either  too  fresh  or  which  has  not 
been  kept  clean  may  cause  flatulency,  colic,  and  diarrhoea,  but  old 
koumiss  has  the  opposite  effect  upon  the  bowels,  and,  like  milk,  gives 
rise  to  constipation.  Koumiss  resembles  whey  in  being  strongly  diu- 
retic and  diaphoretic,  and  thus  relieves  the  mucous  membranes  of 
congestion.  It  also  alleviates  thirst,  strengthens  the  action  of  the 
heart,  and  improves  the  vascular  tone,  general  nutrition,  and  com- 
plexion. The  solids  of  the  urine  are  increased  during  its  use.  The 
use  of  koumiss  is  contraindicated  in  gout  and  chronic  constipation. 

At  first  only  two  or  three  tumblerfuls  of  koumiss  are  allowed  daily 
until  the  stomach  becomes  accustomed  to  it;  then  patients  are  made 
to  drink  a  glass  at  frequent  intervals  during  the  day  and  sometimes 
as  often  as  once  every  half  hour.  Some  patients  can  digest  very  large 
quantities  of  koumiss,  and  as  much  as  10  quarts  have  been  taken  in 
twenty-four  hours;  but  less  is  used  now  than  formerly;  patients  do 
not  often  exceed  6  or  8  quarts  a  day,  and  for  the  average  from  2  to  4 
is  quite  enough.  Tender  beef  and  abundant  butter,  cream,  and  a 
moderate  supply  of  bread  compose  the  basis  of  the  other  foods  allowed. 
Sweets,  salads,  and  other  beverages  than  koumiss  are  forbidden. 

The  treatment  should  be  commenced  slowly  in  order  to  accustom 
the  digestive  system  to  the  fermented  drink,  which  otherwise  may 
excite  diarrhoea.  The  latter  accident  may  be  counteracted  by  lime 
water  or  some  simple  remedy,  such  as  bismuth. 

The  koumiss  prepared  from  milk  in  the  United  States  does  not 
seem  to  possess  the  peculiar  properties  and  extraordinary  nutritive 
value  which  is  attributed  to  it  when  made  from  mare's  milk  in  Eus- 
sia,  on  which  patients  are  said  to  gain  rapidly  in  weight.  In  various 
Eussian  cities  there  are  special  institutions  designed  for  carrying  out 
the  koumiss  cure,  and  which  are  supplied  with  the  genuine  article 
from  the  steppes. 


VARIOUS  OTHER       CURES  803 

Special  koumiss  cures  are  not  in  vogue  in  this  country,  but  in 
southeastern  Kussia  there  are  several  establishments,  notably  in  the 
districts  of  Orenberg  and  Samara,  where  patients  go  for  treatment 
during  several  months  in  summer,  and  derive  great  improvement. 
Like  other  popular  "  cure  "  resorts  in  Europe,  these  establishments 
furnish  the  patient  with  suitable  light  and  varied  amusement  during 
the  progress  of  this  treatment,  which  is  highly  beneficial,  by  diverting 
the  mind  and  relieving  an  otherwise  monotonous  regime.  While 
undergoing  the  koumiss  cure,  patients  are  made  to  live  outdoors  as 
much  as  possible,  and  tent  life  with  free  exercise  is  no  doubt  a  very 
important  adjunct  to  the  treatment  when  it  can  be  obtained.  The 
climate  is  both  hot  and  dry,  and  the  elevation  is  high. 

The  koumiss  cure  is  particularly  available  for  chronic  catarrh  of 
the  respiratory  and  alimentary  canal,  and  in  the  first  stage  of  pul- 
monary tuberculosis.  It  is  also  especially  recommended  for  general 
debility  resulting  from  pronounced  anaemia,  and  for  various  diathesis, 
such  as  scrofula,  rhachitis,  etc.  The  large  percentage  of  carbonic 
acid  which  is  produced  by  koumiss  fermentation,  together  with  the 
alcohol  present,  acts  as  a  stimulant  to  the  gastric  mucous  membrane, 
favorably  affects  digestion,  and  lessens  irritability  of  the  stomach. 
Among  other  effects  produced  by  the  use  of  koumiss  may  be  men- 
tioned occasional  drowsiness  and  lassitude.  This  food  is  also  said 
to  possess  some  aphrodisiac  influence. 

It  is  probable  that  a  large  share  of  the  benefit  claimed  for  the  na- 
tive "koumiss  cure"  is  attributable,  like  most  "cures,"  to  the  favor- 
able climate  in  which  the  patients  live,  especially  during  the  months 
of  May,  June,  and  July,  where  the  air  is  dry,  clear,  and  aromatic. 

Very  advanced  cases,  and  those  having  active  fever,  may  not  be 
benefited  by  the  "cure,"  but  koumiss  may  be  given  the  patients  at 
home.  Koumiss  is  of  service  as  an  easily  digested  food  for  many 
cases  of  obstinate  gastric  irritation  and  severe  vomiting,  especially  in 
alcoholic  gastritis.  In  the  latter  it  may  be  tolerated  when  no  other 
nutriment  is  retained.  Its  uses  are  therefore  various  both  for  infants 
and  adults,  and  there  are  cases  in  which  it  agrees  better  than  pan- 
creatinized  milk  or  milk  prepared  in  any  other  way. 

VARIOUS  OTHER  "  CURES  " 

There  are  other  diet  systems  or  "cures,"  which  deserve  passing 
mention  rather  as  matter  of  general  interest  and  illustrations  of  the 
effects  of  strong  mental  impressions  or  "  mind  cure  "  combined  with 
moderation  in  previous  habits  of  overeating  or  gluttony,  than  because 


804  DIETARIES,  RATIONS 

any  specific  importance  is  to  be  attached  to  the  value  of  one  such 
"cure"  more  than  another. 

Many  diet  "  cures "  have  been  devised  purely  for  notoriety,  to 
advertise  an  otherwise  unsuccessful  practitioner  or  a  charlatan,  and 
others  again  are  exploited  by  well-meaning  fanatics  who  have  ac- 
quired a  firm  bejief  in  some  dietetic  system  which  has  first  helped 
themselves,  and  which  they  feel  that  they  owe  to  the  world  to  pro- 
mulgate for  the  guidance  of  others.  But  they  are  not  always  even 
pretended  followers  of  ^sculapius.  Mr.  Banting  (p.  697),  whose 
name  has  given  rise  to  a  verb  meaning  to  reduce  corpulency,  was  a 
layman,  and  so  was  Mr.  Graham,  whose  name  is  a  household  adjective 
applied  to  the  flour  which  he  introduced,  and  many  famous  men,  like 
Shelley  and  Goldsmith,  have  sung  the  praises  of  vegetarianism.  Not 
infrequently  an  element  of  religious  fervor  is  added  to  the  belief  in 
the  efficacy  of  some  new  system,  and  long  pilgrimages  are  made  to 
seek  its  chief  apostle.  Such,  for  example,  is  the  Kneipp  system. 

The  Kneipp  System. —  Monseigneur  Kneipp  was  a  Bavarian  priest 
whose  patients  lived  chiefly  upon  a  diet  of  milk,  coarse  bread  of  bran 
and  flour,  soup,  and  cooked  fruits,  with  a  minimum  of  meat,  eggs, 
and  vegetables.  Water  was  principally  drunk,  with  a  little  wine  or 
beer,  but  no  spirits  or  coffee.  This  is  undoubtedly  a  common-sense 
regimen  for  many  persons  who  have  long  abused  their  gastronomic 
powers  by  eating  too  much  and  too  rich  food,  but  the  ascetic  ele- 
ments are  added  of  wearing  very  light,  loose  apparel  and  walking 
.about  barefooted  in  the  grass  before  the  morning  dew  vanishes. 

FRUIT  CURES 

The  "fruit  cure"  appears  in  many  forms.  At  one  time  it  is 
confined  to  oranges,  English  walnuts,  and  cold  water,  and,  strange  to 
say,  some  dyspeptics  are  able  to  assimilate  the  diet  for  a  short  time; 
or  it  consists  of  sweet  fruits  and  meat  alone  —  dates,  figs,  prunes, 
bananas,  and  apples  —  upon  the  theory  that  fruits  were  the  food  of 
primeval  man,  and  ergo  they  are  the  natural  food  of  all  men  —  an 
extreme  of  atavism,  surely !  There  is  also  a  "  lemon  cure." 

Another  fruit  cure  extends  through  six  weeks.  It  begins  grad- 
ually by  eating  an  apple  or  orange  upon  rising  and  again  upon  retir- 
ing. In  three  or  four  days  the  breakfast  consists  of  several  baked 
apples,  a  small  quantity  of  bread  and  butter,  and  a  little  coffee.  Dur- 
ing the  forenoon  several  ripe  apples  or  oranges  may  be  eaten.  At 
dinner  fresh  animal  food  is  furnished  with  a  potato  and  roasted  apples 
or  apple  sauce.  Green  vegetables  are  allowed,  but  no  bread  or  pastry 


THE      GRAPE  CURE "  805 

of  any  kind.  Pickles  may  be  eaten.  During  the  afternoon,  more 
fruit,  oranges,  apples,  grapes.  Supper,  like  breakfast,  with  a  little 
sago  in  milk,  with  currants,  raisins,  or  apples.  This  diet  is  adapted 
to  obstinate  chronic  constipation,  some  cases  of  obesity,  and  lithaemia. 

THE  "  GRAPE  CURE  " 

The  "  grape  cure  "  has  been  advocated  for  many  years  as  beneficial 
in  certain  forms  of  disease,  but,  as  in  the  majority  of  vaunted  dietetic 
"cures,"  the  chief  benefit  experienced  is  from  the  change  of  scene 
and  the  favorable  climatic  and  hygienic  surroundings  of  the  patient, 
and  possibly  the  influence  of  a  stimulated  imagination.  The  "  cure  " 
is  in  vogue  during  the  grape-bearing  season  of  the  vineyards  in  vari- 
ous parts  of  southern  Europe,  especially  at  Vevey,  Meran,  and  Mon- 
treux.  The  altitude  of  each  of  the  two  former  resorts  is  1,000  feet, 
which  probably  contributes  a  large  share  of  the  benefit  of  the  "  cure." 

Grapes,  being  very  largely  composed  of  water,  do  not  possess  a  very 
high  degree  of  nutritive  power,  and  it  is  impossible  to  maintain  life 
upon  their  exclusive  use;  but  the  grape  sugar  which  they  contain,  as 
well  as  a  large  amount  of  potassium  and  other  salts,  may  have  some 
slight  alterative  effect  and  benefit  nutrition.  Grapes  are  also  laxative. 
Almost  every  one  is  fond  of  the  fruit,  and  the  cure  is  therefore  an 
agreeable  one  to  take,  especially  as  the  diet  is  not  too  exclusive,  for  the 
eating  of  large  quantities  of  grapes  is  made  an  adjunct  to  the  inges- 
tion  of  highly  nutritious  food. 

Vineyard  laborers  who  eat  little  else  but  grapes  quickly  lose  weight, 
and  other  food  must  be  taken  with  the  grapes  if  the  strength  is  to  be 
maintained,  for  a  pound  of  grapes  contains  a  little  less  than  45  grains 
of  protein. 

It  is  recommended  by  Lebert  that  the  grapes  should  be  eaten  sys- 
tematically in  quantities  commencing  with  half  a  pound,  and  seldom 
exceeding  four  pounds  per  diem,  although  six  or  eight  pounds  are 
sometimes  eaten,  a  quantity  which  may  give  rise  to  diarrhoea.  Owing 
to  the  mildly  laxative  effect  of  the  fruit,  this  "  cure  "  is  beneficial  in 
cases  of  chronic  constipation,  and  especially  in  engorgement  and 
hyperaemia  of  the  liver  accompanied  by  extensive  venous  congestion, 
hemorrhoids,  and  the  formation  of  various  forms  of  calculi.  In  gas- 
tric catarrh  patients  are  sometimes  allowed  to  eat  six  pounds  of  grapes 
a  day.  The  laxative  effect  is  greater  if  the  fruit  be  taken  in  the 
intervals  between  meals,  and  especially  if  taken  immediately  on  ris- 
ing in  the  morning.  At  first  only  half  a  pound  of  grapes  is  to  be 
eaten  two  or  three  times  a  dav,  from  half  an  hour  to  an  hour  before 


806  DIETARIES,   RATIONS 

meals,  the  quantity  being  gradually  increased  to  a  pound  or  more  at 
each  dose.  Some  patients  digest  the  grapes  better,  however,  if  they 
are  eaten  in  the  form  of  dessert  than  if  taken  into  an  empty  stomach. 
The  laxative  effect  gradually  increases,  and  is  usually  more  pro- 
nounced after  several  days.  The  uric  acid  and  acidity  of  the  urine 
is  lessened. 

When  patients  become  tired  of  the  monotony  of  this  single  fruit 
they  may  be  allowed  to  substitute  pears  or  figs.  It  is  stated  that  the 
gums  may  become  somewhat  swollen  and  tender  from  the  acid  con- 
tained in  so  much  fruit,  and  to  obviate  this  difficulty  the  mouth  may 
be  cleansed  thoroughly  after  eating  with  a  solution  of  sodium  bicar- 
bonate or  boric  acid,  or  the  mastication  of  a  small  quantity  of  bread 
serves  to  cleanse  the  teeth. 

Abundant  other  food  is  allowed  with  the  grapes,  but  it  is  impor- 
tant that  it  should  be  of  an  easily  digestible  character,  and  certain 
foods  are  therefore  forbidden,  such  as  fats,  rich  sauces,  gravies,  pickles, 
condiments,  the  heavier  vegetables,  such  as  potatoes  and  the  legumes, 
cheese,  pastry,  cakes,  sweets,  and  beer. 

The  usual  duration  of  the  cure  is  from  a  month  to  six  weeks. 

Patients  who  have  undertaken  the  grape  cure  without  proper  super- 
vision may  disorder  their  digestion  and  cause  gastric  catarrh  and 
even  jaundice.  Knauthe  says  that  the  eating  of  several  pounds  of 
grapes  daily  may  at  first  cause  symptoms  of  flatulent  dyspepsia,  more 
or  less  vertigo,  and  increased  frequency  of  the  pulse,  palpitation, 
diuresis,  and  malaise.  The  stools  become  more  frequent  and  semi- 
solid. 

The  grape  cure  is  reputed  to  be  serviceable  in  chronic  bronchitis, 
the  first  stage  of  phthisis,  emphysema,  in  obesity  when  combined  with 
a  reduced  diet,  in  gastrointestinal  catarrh,  anaemia,  vesical  catarrh, 
gout,  hepatic  engorgement,  malarial  cachexia,  and  chronic  cutaneous 
affections.  In  phthisis  the  grapes  should  not  be  given  in  quantities 
sufficient  to  occasion  diarrhoea. 

The  composition  of  grapes  is  given  on  page  219. 

THE  "  MEAT  AND  HOT- WATER  CURE  " 

The  meat  and  hot-water  cure,  often  called  in  this  country  by  the 
name  of  Salisbury,  one  of  its  chief  advocates,  is  given  to  many 
classes  of  patients  —  consumptives,  rheumatic  subjects,  and  others. 
Lean  raw  beef  is  ground  to  a  pulp  in  a  machine  which  is  made  for 
the  purpose  and  sold  in  hardware  shops.  It  is  freed  from  all  fiber, 
seasoned  with  salt  and  pepper,  rolled  into  little  balls,  and  cooked  just 


THE      DRY  CUBE  '  807 

enough  to  turn  the  outside  from  red  to  a  drab  color.  From  two  to 
four  ounces  are  eaten  at  a  meal  at  first ;  later  as  much  as  seven  ounces 
may  be  taken.  In  addition,  from  two  to  four  raw  eggs  are  given  with 
dry  toast,  but  no  other  food.  Xo  fluid  is  allowed  with  meals,  but 
from  a  half  pint  to  a  pint  of  hot  water  is  given  before  each  meal,  and 
again  at  bedtime. 

This  diet  reduces  corpulency  rapidly,  and  is  recommended  also  for 
chronic  gastric  catarrh  and  dilatation,  but  is  too  rigid  for  many 
patients.  It  is  somewhat  similar  to,  but  more  restricted  than,  the 
diets  of  Carlsbad  and  Wiesbaden,  which  consist  chiefly  of  lean  meat, 
eggs,  and  milk  with  a  minimum  of  bread,  and  sometimes  fruit. 

THE  "  DRY  CURE  " 

The  "  dry  cure  "  is  the  name  given  to  the  treatment  which  con- 
sists in  withholding  fluid  from  the  diet  in  increasing  degree  until  the 
patient  takes  barely  as  much  as  is  necessary  to  sustain  life.  If  carried 
to  this  extreme,  however,  thirst  becomes  intolerable,  and  patients 
usually  rebel  against  the  harshness  of  such  treatment. 

Practically  it  is  found  that  the  minimum  of  water  aside  from  that 
contained  in  food  which  patients  can  tolerate  is  about  fifteen  ounces 
per  diem,  which  should  be  taken  between  meals.  For  the  relief  of 
thirst  in  these -cases  various  measures  are  employed,  such  as  are 
described  on  p.  43. 

In  Germany  the  dry  diet  has  been  tried  extensively  in  some  cases, 
especially  those  of  gastric  dilatation  and  cases  of  chronic  effusion 
into  the  joints  and  in  the  peritoneal  cavity.  There  are  many  forms 
of  disease  in  which  it  is  well  temporarily  to  restrict  very  much  the 
quantity  of  food  consumed,  but  it  is  hardly  ever  justifiable  to  do  so 
to  the  degree  recommended  by  enthusiastic  advocates  of  the  "  dry 
cure/'  among  whose  patients  fatal  cases  of  scurvy  have  occurred  as 
well  as  cases  of  fever  with  a  temperature  sometimes  amounting  to 
104°  F.  The  conditions  in  which  the  quantity  of  fluid  drunk  should 
be  especially  reduced  are  gastric  dilatation,  chronic  serous  effusions, 
flatulent  dyspepsia  due  to  indulgence  in  sweets,  coffee,  tea,  etc., 
obesity,  general  anasarca,  and  aneurism  of  the  aorta  (compare  Tuf- 
nell's  treatment,  p.  536). 

This  treatment  is  undesirable  in  chronic  nephritis  with  renal  in- 
adequacy. 

Schroth's  Method  of  "  Dry  Cure." —  The  dry  cure  of  the  yeoman 
John  Schroth  has  achieved  some  notoriety  in  Europe,  where  several 
"  institutes  "  have  been  established  for  its  practice.  It  is  a  rigorous 


808  DIETARIES,   RATIONS 

method  which  many  patients  find  difficult  to  endure.  The  diet  is 
gradually  reduced  in  quantity  and  variety  at  first  for  a  few  days,  and 
then  the  actual  "  cure  "  is  begun,  which  consists  in  giving  no  fluid  at 
all,  excepting  a  small  glass  of  hot  wine  twice  a  day  for  as  many  days 
as  the  patient  will  endure  it.  Boiled  vegetables  are  allowed  for  din- 
ner, and  otherwise  nothing  is  given  but  dry  bread.  Thirst  becomes  so 
extreme  that  in  three  or  four  days  the  patient  is  allowed  to  drink  hot 
wine  freely  to  quench  it,  after  which  the  quantity  of  fluid  is  again  cut 
down  to  two  small  glasses  a  day  until  the  patient  is  again  obliged  to 
receive  more. 

This  treatment  has  in  some  cases  been  carried  to  the  verge  of 
starvation  with  extreme  prostration  and  fever,  and  it  has  little  or 
nothing  to  recommend  it.  Fatal  scurvy  has  followed  its  use  at  Kiel. 
It  is  based  upon  the  theory  that  the  blood  becomes  more  dense,  which 
favors  osmosis  between  the  serum  and  the  surrounding  lymph  and 
tissues.  As  an  adjunct  to  the  treatment  hot  moist  packing  is  em- 
ployed. 

Jiirgensen  modified  the  treatment  by  giving  from  one-third  to 
two-thirds  of  a  pound  of  lean  beef  with  bread  as  desired,  and  light  red 
wine.  It  has  been  found  by  this  writer  and  by  Bartels  that  proteid 
metabolism  is  increased  by  the  dry  diet,  for  the  urine  contains  pro- 
teid waste  in  as  large  a  proportion  as  when  the  patient  is  upon  a  full 
diet  —  in  some  cases  there  is  even  more  than  the  normal. 

Upon  slowly  resuming  the  accustomed  diet  a  considerable  gain 
in  weight  compensates  for  previous  loss,  which  is  attributed  in  part 
to  restoration  of  water  to  the  tissues.  Bartels  noted  an  increase  in 
urea  which  was  greatest  immediately  after  the  treatment.  The  con- 
siderable rise  of  temperature  (104°  F.)  which  accompanies  this  treat- 
ment is  explained  by  the  facts  that  little  water  is  evaporated  from  the 
lungs  and  skin,  and  the  body  heat  is  retained  by  the  hot  packs. 

The  treatment  has  been  applied  with  some  success  in  obstinate 
cases  of  syphilis,  gastric  dilatation,  chronic  rheumatism,  and  chronic 
peritonitis. 

Purin  Free  Diet. —  Much  has  been  written  of  late  as  to  certain 
katabolic  products  derived  chiefly  from  ingested  nucleins  and  collec- 
tively called  purins.  The  purin  bases  are  xanthin,  hypoxanthin, 
adenin  and  guanin,  substances  obtainable  from  meats,  meat  extracts, 
liver,  pancreas,  the  husks  of  grain  (as  in  oatmeal,  whole  wheaten 
meal,  etc.),  peas,  beans,  tea,  and  coffee. 

Hence  a  purin  free  diet  must  exclude  the  above-mentioned  foods, 
but  may  include  milk,  cream,  butter,  eggs,  rice,  potatoes,  macaroni, 
and  such  fruit?  as  apples,  oranges,  grapes,  and  bananas.  The  purins 


DIET   IN   ATHLETIC   TRAINING  809 

produce  more  or  less  toxic  effect  when  ingested  in  excess,  and  are 
believed  by  Haig  and  others  to  be  especially  injurious  in  cases  of  gout, 
rheumatism,  gravel,  and  arteriosclerosis.  The  purin  bodies  are  closely 
associated  in  their  formation  with  uric  acid.  About  half  the  purins 
excreted  in  the  urine  are  derived  from  the  ingested  food  and  half 
from  tissue  waste. 


DIET  IN  ATHLETIC  TRAINING 

The  object  of  dietetic  "  training  "  in  athletics  is  to  fit  men  either 
for  feats  of  great  muscular  endurance  and  strength  or  for  exhibitions 
of  dexterity  requiring  accurate  and  quick  muscular  movements  and 
nerve  control.  Th°  method  of  training  naturally  differs  consider- 
ably according  to  the  object  to  be  attained.  Professional  athletes, 
who  are  more  or  less  constantly  employed  in  exhibitions  of  strength 
or  muscular  skill,  are  obliged  to  adopt  very  regular  habits  of  life  in 
regard  to  sleep,  bathing,  and  diet,  and  abstinence  from  the  excessive 
use  of  tobacco  and  strong  drink.  In  addition,  when  they  enter  spe- 
cial contests  requiring  continued  feats  of  endurance,  as  in  prolonged 
bicycle  races  or  walking  matches,  for  example,  they  have  to  undergo 
a  period  of  special  training  for  several  weeks  before  the  contest. 
Young  men  who  devote  themselves  to  athletic  sports  in  college 
usually  do  so  for  a  comparatively  limited  period,  and  are  not  sub- 
jected to  such  special  strain  or 'feats  of  endurance  excepting,  per- 
haps, in  boat  races,  which  are  of  short  duration.  As  a  general  rule, 
from  six  to  ten  weeks  is  ample  time  to  cover  their  course  of  special 
dietetic  training,  although  they  usually  exercise  ordinary  care  in  such 
matters  for  a  longer  period  before  their  contests. 

The  physiological  objects  to  be  attained  by  any  system  of  dietetic 
training  are  to  reduce  the  fat  and  water  contained  in  the  tissues  of 
the  body,  to  increase  the  functional  activity  of  the  muscles,  to  train 
both  muscles  and  nerves,  improve  the  breathing  power  or  "wind," 
the  heart  action  and  the  condition  of  the  skin.  This  is  accomplished 
by  carefully  regulated  diet,  systematic  exercises  directed  to  the  in- 
crease of  oxidation  processes,  and  the  more  perfect  elimination  of 
waste  matter  from  the  system.  Dietetic  training  supplies  an  excess 
of  protein  to  make  good  any  loss  of  this  material.  The  protein  is 
needed  to  renew  and  build  up  muscle  protoplasm. 

Eigorous   dietetic  training  should  be  conducted  with  great  care 

and  supervised  only  by  those  who  are  experienced  in  such  matters, 

for  any  system  carried  to  excess  may  cause  too  great  a  reduction  in 

weight,  and  its  object  will  be  defeated  by  breaking  down  the  indi- 

54 


810  DIETAEIES,   RATIONS 

vidual  at  the  moment  of  critical  contest  or  laying  the  foundation  for 
future  organic  weakness  and  disease.  The  heart  may  become  hyper- 
trophied  and  subsequently  fail  in  accommodation. 

It  may  be  observed,  however,  that  much  of  the  ill  effect  of  ath- 
letic training  may  be  due  not  so  much  to  any  particular  form  of 
exertion  or  to  being  trained  "  too  fine  "  in  diet,  but  to  the  fact  that 
the  training  brings  to  light  constitutional  weaknesses  which  were 
unsuspected  until  revealed  by  unwonted  effort  —  in  short,  the  system 
involves  survival  of  the  fittest. 

The  transition  for  ordinary  diet  to  that  of  any  training  system 
should  be  made  gradually,  and  the  return  to  the  usual  diet  after  a 
period  of  strict  training  should  be  similarly  slow.  For  the  first  two 
or  three  weeks  of  training  athletes  usually  lose  in  weight  an  amount 
proportionate  to  their  previous  condition  of  robustness,  but  after 
several  weeks  an  equilibrium  should  be  reached  in  which,  upon  an 
established  diet,  the  body  weight  remains  practically  the  same  while 
the  muscular  strength,  vigor,  and  power  of  endurance  increase;  the 
complexion  improves  in  appearance,  the  skin  becomes  clearer,  the 
muscles  firmer,  and  all  superfluous  fat  disappears. 

While  individual  dietaries  differ  in  training  for  the  various  forms 
of  contest,  most  of  them  include  lean  meat,  chiefly  rare  or  "  under- 
done," either  roasted  or  broiled;  the  bread  should  be  dry  or  toasted, 
and  a  moderate  quantity  of  potatoes  and  fresh  green  vegetables  and 
fruits  are  usually  allowed.  The  class  of  foods  to  be  especially  forbid- 
den are  sweets,  pastry,  entrees,  rich  puddings,  sour  pickles,  and  condi- 
ments. For  beverages,  weak  tea,  or  coffee  may  be  allowed,  although 
sometimes,  where  the  object  of  training  is  the  attainment  of  special 
skill  in  feats  of  delicate  balancing,  all  forms  of  nerve  stimulants, 
including  tea,  coffee,  and  tobacco  should  be  prohibited.  Chocolate 
and  cocoa,  if  not  too  sweet,  sometimes  may  be  allowed,  and  in  some 
training  systems  the  use  of  light  beer  and  light  wine  in  moderation 
is  included,  but  strong  alcoholic  spirits  are  absolutely  forbidden.  As 
a  rule,  three  meals  a  day  at  intervals  of  between  five  and  six  hours  are 
recommended. 

The  ancient  Greek  and  Eoman  athletes  used  to  train  very  largely 
upon  a  dry  diet,  which  at  first  consisted  of  fresh  cheese,  dried  figs, 
and  preparations  of  wheat.  Later  they  ate  such  meats  as  pork,  beef, 
and  goat  flesh. 

Parkes  gives  the  quantity  of  fluid  which  may  be  allowed  as  about 
five  pints  in  winter  and  six  in  summer,  a  little  over  one-fourth  of 
which  i?  contained  in  the  food.  Drink  should  not  be  taken  either 
shortly  before  exercise  or  during  meals.  If  the  mouth  be  well  rinsed 


DIET   IN   ATHLETIC   TRAINING  811 

before  drinking,  less  fluid  will  be  required,  and  what  is  taken  should 
be  drunk  slowly. 

The  use  of  tobacco,  particularly  in  the  form  of  cigarette  smoking, 
should  be  forbidden,  and  as  alcohol  in  excess  lessens  the  power  of 
sustained  muscular  exertion,  only  beverages  containing  not  over  two 
ounces  may  be  allowed  per  diem. 

The  following  dietaries  of  training  have  been  kindly  furnished  me 
by  Dr.  John  S.  Hartwell,  who  has  had  much  personal  experience  in 
such  matters: 

Dietary  of  the  Boat  Crew  at  Yale  University 

From  March  1st  till  June  10th  (ten  weeks  and  a  half),  the  hours 
of  work  are  from  4  to  7  P.  MV  with  exercise  for  half  an  extra  hour  or 
more  at  such  odd  times  as  recitations  may  permit.  During  .this  pe- 
riod the  following  regulations  of  the  training  table  are  observed: 

Breakfast,  7.30  A.  M. 

Fruit. —  Oranges,  tamarinds,  figs,  or  dates. 

Cereals. —  Oatmeal  or  one  of  the  many  preparations  of  wheat ;  a  rich  milk 
(not  cream)  and  sugar  are  allowed  with  this.  Toast.  No  hot  breads  are 
allowed. 

Meats. —  Beefsteak  (usually  rare),  chops,  stews,  or  hash.  Once  or  twice 
a  week  salt  meat,  as  bacon  or  ham,  is  allowed,  and  with  it  usually  liver. 
The  meats  are  varied,  steaks  or  chops  alternating  with  one  of  the  others. 

Potatoes. —  Stewed,   browned,   or   baked. 

Eggs.—  Served  in  all  styles,  except  fried  (unless  with  the  ham).  Eggs 
appear  in  some  form  about  four  mornings  a  week. 

Fluids. —  Oatmeal  water,  milk,  and  tea  on  special  occasions  for  some  indi- 
vidual man.  The  water  is  boiled  and  poured  while  hot  on  the  oatmeal.  On 
cooling  it  has  about  the  consistence  of  rich  milk  and  a  strong  flavor  of  the 
oatmeal. 

Dinner 

Soups. —  All  varieties,  including  oyster  stews  and  clam  broths. 

Meats. —  Roast  beef,  mutton,  turkey,  or  chicken.  Gravies  are  but  little 
used.  Two  kinds  of  meat  are  always  served. 

Fish,  broiled  or  boiled,  is  served  twice  a  week. 

Vegetables. —  Potatoes  (mashed  or  boiled).  Tomatoes,  stewed  or  some- 
times raw.  Beans,  peas,  corn  (occasionally).  Two  vegetables  besides  po- 
tatoes are  usually  served. 

Toast. 

Dessert. —  Puddings  —  rice,  bread,  or  tapioca;  little  butter  is  allowed  in 
their  preparation. 

Fruit. —  Same  as  breakfast,  with  berries  and  cantaloupe  in  season.  Baked 
apples. 

Fluid. —  Same  as  breakfast. 

Supper   (one  hour  after  rowing  —  i.  e.,  from  1  to  8.15  P.  M.) 

Cereals. —  Same  as  breakfast. 

Meats. —  Chops,  stews,  cold  meats  from  dinner.     Rarely,  beefsteak. 

Potatoes. —  Stewed  or  baked. 

Eggs. —  All  styles,  about  three  times  a  week,  usually  not  on  same  day  as  for 
breakfast. 

Fluids. —  Same  as  breakfast.  Bass's  ale  for  men  who  are  getting  "  fine  " 
and  for  whole  crew  after  especially  hard  clay's  work. 

Ale  and  milk  are  never  taken  at  the  same  meal. 


812  DIETAKIES,   RATIONS 

For  three  weeks  following  June  10th  the  crew  is  at  K"ew  London 
in  final  preparation  for  their  race.  The  program  is  then  some- 
what changed. 

Breakfast  is  served  at  the  same  hour  and  consists  of  the  same 
variety  of  food  as  before. 

The  morning  work  is  from  9.30  or  10  to  11.30  or  12. 

Dinner,  with  same  menu  as  before,  is  served  at  12.30  or  1  p.  M. 

Luncheon. —  The  afternoon  till  4.30  is  spent  in  loafing  —  often  on 
the  water  in  the  steam  launch.  At  that  hour  a  lunch  of  cold  meat, 
stewed  or  baked  potatoes,  milk,  and  toast  is  served.  The  afternoon 
work  —  which  is  the  hard  work  of  the  day  —  begins  from  forty-five 
to  sixty  minutes  after  the  lunch  and  continues  for  about  two  hours, 
more  or  less,  depending  on  its  severity.  Forty-five  minutes  after  this 
work  cold  oatmeal  or  other  cereal,  with  toast  and  milk,  is  served. 

Many  of  the  men  are  allowed  ale  every  night  during  the  final  three 
weeks,  either  with  the  late  supper  or  an  hour  later  —  9.30,  on  retiring. 

Quantity  of  Food  and  Fluid. —  There  is  no  limit  set  to  the  quantity 
of  food.  The  fluids,  however,  are  limited  to  three  glasses  at  a  meal, 
with  little  drink  between  meals.  Of  late  years  this  is  becoming 
changed,  and  in  hot  weather,  when  the  men  are  perspiring  freely, 
more  fluid  is  allowed.  To  counteract  the  constipating  effect  which 
training  has  upon  some  men,  stewed  prunes  are  served  for  either 
breakfast  or  supper. 

The  training  table  of  the  present  day,  as  given  above,  is  far  more 
liberal  than  it  was  ten  years  earlier,  and  it  is  aimed  to  regulate  it 
on  a  rational  basis.  What  few  statistics  are  at  command  seem  to  show 
that  the  new  system  is  an  improvement  on  the  old,  and  cases  of  over- 
training are  less  frequent  and  less  serious  now  than  formerly. 

It  is  the  opinion  of  J.  W.  White  that  "  an  ordinary  farmhouse  table 
with  its  midday  dinner  and  early  tea  will  rarely  (with  the  exception 
of  coffee,  hot  cakes,  pastry,  and  fried  meats)  offer  anything  which 
should  be  excluded  from  a  rational  training  diet  as  it  is  at  present 
understood. 

Diet  of  Harvard  University  Crew 

The  Harvard  University  Boat  Crew  diet  while  in  active  training 
was  studied  for  six  days  by  W.  0.  Atwater  and  A.  P.  Bryant.  The 
average  weight  per  man  was  162  pounds.  A  daily  loss  of  from  2  to 
3%  pounds  per  man  was  produced  by  rowing  and  restored  before  the 
next  day.  (As  much  as  4!/4  pounds  is  sometimes  lost  by  a  man  dur- 
ing a  four-mile  race,  and  iy>  pound  may  be  lost  through  worry  and 
excitement  immediately  preceding  the  race.) 


DIET  IN   ATHLETIC   TRAINING  813 

"  The  diet  was  simple.  Eoast  and  broiled  beef  and  lamb,  fric- 
asseed chicken,  roast  turkey,  and  broiled  fish,  made  up  the  meats. 
Eggs  were  used  plentifully  either  raw,  poached,  or  boiled  in  the  shell. 
Large  amounts  of  milk  and  cream  were  also  consumed.  Oatmeal, 
hominy,  and  shredded  wheat  were  eaten  largely,  and  corn  cakes  were 
occasionally  served.  Bread  was  almost  always  taken  in  the  form  of 
dry  toast.  Potatoes  were  served  twice  a  day.  These  were  sometimes 
baked,  sometimes  boiled  and  mashed  with  a  little  milk  and  butter 
added,  and  at  other  times  'creamed.'  Boiled  rice,  prepared  with  a 
little  cream  and  sugar,  was  served  instead  of  potatoes  at  some  meals. 
Beets,  parsnips,  green  peas,  and  tomatoes  were  used  to  furnish  a 
variety  of  vegetables.  Macaroni  was  occasionally  served.  For  des- 
sert, apple  tapioca  pudding,  custard  pudding,  or  other  pudding  con- 
taining a  large  proportion  of  milk  and  eggs  was  used.  The  mem- 
bers of  the  crew  were  allowed  beer  once  a  day.  No  pastry  was  allowed, 
and  the  puddings  were,  as  above  stated,  composed  largely  of  eggs  and 
milk.  A  small  amount  of  coffee  jelly  was  served,  and  at  one  meal 
during  the  study,  ice  cream.  No  fresh  fruit  was  served,  with  the 
exception  of  oranges  for  breakfast.  Stewed  prunes,  rhubarb,  or  ap- 
ples were  also  eaten,  prunes  most  abundantly.  No  beverages  were 
allowed  other  than  water,  milk,  and  beer.  Breakfast  was  served  at 
8,  lunch  at  1,  and  dinner  at  6  o'clock/' 

These  experimenters  found  that  the  average  nutrients  consumed 
per  man  per  diem  amounted  to  145  grams  protein,  170  grams  fat, 
and  375  grams  carbohydrates,  aggregating  3,705  calories.  Just  be- 
fore racing  each  man  received  one  ounce  of  beef  extract  with  eight 
ounces  of  dry  toast. 

A  subsequent  study  of  the  Harvard  University  Boat  Crew  was 
made  by  E.  A.  Darling,  who  reported  as  follows : 

"Diet. —  The  diet  allowed  was  a  very  generous  one,  consisting  of 
a  hearty  breakfast  at  7.30,  lunch  at  1,  and  dinner  after  the  even- 
ing row.  For  breakfast  the  fare  consisted  of  fruit,  oatmeal,  or  shred- 
ded wheat,  eggs,  some  form  of  meat,  bread  and  butter,  potato,  and 
milk.  At  noon  there  was  cold  meat,  potato,  bread  and  butter,  mar- 
malade, preserved  fruit,  and  milk.  Dinner  comprised  soup,  occa- 
sionally fish,  roast  beef  or  some  other  hot  meat,  several  vegetables, 
bread  and  butter,  and  a  simple  dessert.  No  tea  or  coffee  was  allowed, 
but  ale  or  claret  was  permitted  at  dinner,  also  water  in  small  amounts, 
as  desired.  During  the  last  week  before  the  race  each  man  received 
a  dish  of  calf's-foot  jelly  with  sherry  wine  after  the  morning  row, 
and  a  light  lunch  of  oatmeal,  milk,  and  bread  was  served  at  4  o'clock 
in  the  afternoon." 


814 


DIETARIES,  RATIONS 


Another  study  of  the  Harvard  Freshman  Crew  during  training  was 
made  by  Atwater  and  Bryant: 

"  The  men  arose  at  about  7  o'clock.  Before-  this  time  no  noise 
was  allowed  in  the  kitchen  or  elsewhere.  After  a  short  run,  break- 
fast was  served  at  7.30  o'clock  and  was  quite  a  hearty  meal,  consist- 
ing principally  of  oranges,  a  breakfast  cereal,  hot  meat  or  fish,  and 
potatoes.  During  the  morning  there  was  usually  a  practice  row  on 
the  river,  followed  by  a  light  lunch  at  about  11.30  to  12  o'clock. 
The  principal  meal  of  the  day  was  taken  early  in  the  afternoon.  In 
the  late  afternoon  the  crew  had  another  season  of  hard  work  on  the 
river,  after  which  another  hearty  meal  was  served.  Leisure  time  was 
spent  in  study  or  recreation." 

Cane  or  grape  sugar  in  large  quantity  may  be  added  with  advantage 
to  the  diet  of  athletes  and  soldiers  on  the  march.  It  may  be  given 
with  other  food,  such  as  cereals,  tea  and  coffee,  etc.,  as  is  customary 
with  the  Cornell  University  Crew;  or  it  may  be  given  separately 
either  as  plain  confectionery  or  in  the  form  of  cakes  of  chocolate.  In 
a  recent  study  of  the  training  diet  of  boat  clubs  in  Holland  as  much 
as  one-third  of  a  pound  of  cane  sugar  per  man  per  diem  was  found  to 
be  consumed  with  very  marked  benefit. 

Summary  of  Results  of  Dietary  Studies  of  University  Boat  Crews  and  ofher 
Dietary  Studies,  by  W.  0.  Atwater  and  A.  P.  Bryant 
(Nutrients  in  food  actually  eaten  per  man  per  day) 


Pro- 
tein. 

Fats. 

Carbo- 
hydrates. 

Fuel 
value. 

DIETARY     STUDIES     OF     UNIVERSITY     BOAT     CREWS 

Harvard    University   crew    at    Cambridge    

Grms. 
162 

Grms. 
175 

Grms. 
449 

Cals. 
4,130 

Harvard    Freshman   crew    at   Cambridge    

153 

223 

468 

4  620 

Yale  University  crew  at  New  Haven  

145 

170 

375 

3  705 

Harvard   University   crew   at   Gales   Ferry    

160 

170 

448 

4  075 

Harvard    Freshman   crew    at    Gales    Ferry    

135 

152 

416 

3  fi?T 

Yale    University    crew    at    Gales    Ferry    

171 

434 

4  070 

Captain    of    Harvard    Freshman    crew    

TSfi 

181 

487 

4   31  T 

\vpra°re                

l^T 

440 

4  ORTi 

SUMMARISED    RESULTS    OF    OTHER    DIETARY    STUDIES 

Football    team,    college    students,    Connecticut    .  . 
Football    team,    college    students,    California     .  .  . 
Professional  athlete,  Sandow    

181 
270 
244 

292 
416 
151 

557 
710 
502 

5,740 

7,885 
4,460 

Pri/e  fighter.  England  

278 

78 

83 

2,205 

Average  of   15  college  clubs    

107 

148 

459 

3,690 

Average  of  14  mechanics'  families    

103 

150 

402 

3,465 

Average  of  10  farmers'  families    

97 

130 

467 

3,515 

Average  of  24  mechanics'  and  farmers'    families. 
Average  of  14  professional  mens'  families    

100 
104 

141 
125 

429 
423 

3,480 
3,325 

DIET   IN   ATHLETIC    TRAINING 


815 


Pro 
tem. 

Fats. 

Carbo- 
hydrates. 

Fuel, 
values. 

DIETARY   STANDARDS 

Man  with  moderate  muscular  work,  Voit     

Grms. 
118 
119 
125 
145 
156 
150 
185 
175 

Grms. 
56 
51 

ioo 

71 

'ii 

Grms. 
500 
531 

450 
568 

568 

Cats. 
3,055 
3,140 
3,500 
3,370 
3,630 
4,500 
3,750 
5,700 

Man  with  moderate  muscular  work,  Playfair    .  .  . 
Man  with  moderate  muscular  work,  Atwater    .  .  . 
Man  with  hard  muscular  work,  Voit    

Man  with  hard  muscular  work,  Playfair    

Man  with  hard  muscular  work,  Atwater    

Man  with  severe  muscular  work,  Playfair   

Man  with  severe  muscular  work,  Atwater   

Diet  of  Yale  Football  Team 

"  The  diet  of  the  football  team  is  practically  the  same  as  for  the 
crew  except  for  lunch,  which  is  eaten  at  1  p.  M.,  the  practice  taking 
place  from  2.30  to  3.45  or  4  p.  M.  This  one-o'clock  meal  consists  of 
cold  meat,  one  chop  or  eggs,  hot  broth  or  bouillon,  and  toast.  Milk 
and  oatmeal-water  are  drunk.  Apple  sauce  is  sometimes  allowed" 
(John  A.  Hartwell). 

Diet  of  Pugilists,  Bicycle  Racers  and  Jockeys 

Chambers  gives  the  following  example  of  a  diet  used  by  pugilists : 

7  A.  M.  Light  breakfast :  oatmeal  with  little  or  no  milk  and  sugar ; 
one  to  three  eggs,  poached  or  raw;  a  cup  of  tea  with  little  or  no  milk 
or  sugar;  a  slice  or  two  of  toast.  The  eggs  may  be  varied  by  a  rare 
or  well-broiled  chop. 

12  NOON".  Dinner  (following  a  half  hour  of  rest)  :  roasf  beef  or 
mutton  and  vegetables ;  cup  custard  and  plum  pudding.  A  heavy  dinner 
may  be  eaten,  unless  it  is  desired  to  reduce  the  weight.  Old,  mixed, 
or  Bass's  ale  is  allowed,  but  only  a  little  water  should  be  drunk,  for 
it  favors  obesity.  If  thirst  is  annoying,  a  pebble  or  bit  of  rubber  tub- 
ing may  be  carried  and  rolled  in  the  mouth  to  increase  the  flow  of 
saliva. 

An  hour  or  two  of  rest  should  be  taken  after  dining. 

6  p.  M.  Light  supper :  toast,  a  mutton  chop  or  an  egg,  a  vegetable, 
and  a  cup  of  tea. 

Percy  studied  the  diet  of  a  light-weight  prize  fighter  twenty-two 
3rears  of  age,  5  feet  6  inches  in  height  and  weighing  119  pounds. 
"  He  breakfasted  at  9  A.  M.,  and  ate  one  pound  of  mutton,  weighed 
before  cooking.  He  dined  at  1  p.  M.,  and  ate  the  same  quantity  of 
mutton,  with  the  addition  of  about  two  ounces  of  bread.  And  again 
at  supper,  at  8  p.  M.,  he  had  the  same  quantity  of  mutton.  At  each 
meal  he  drank  half  a  pint  of  ale,  but  no  other  liquid  at  any  other 


816  DIETARIES,   RATIONS 

time  of  the  day.  Nor  did  he  eat  any  other  vegetable  matter  whatever 
besides  the  small  quantity  of  bread  mentioned.  He  walked  seven- 
teen miles  per  day." 

Such  a  diet  would  not  be  indorsed  by  most  trainers,  nor  would  it 
fit  a  man  for  sustained  effort. 

A  noted  New  York  prize  fighter  says  that  in  training  he  is  accus- 
tomed to  eat  almost  any  plain  substantial  food  that  he  likes,  relying 
largely  upon  beef,  mutton,  bread,  and  potatoes,  but  avoiding  pastry 
and  sweets.  He  drinks  fluid  freely  until  within  a  week  of  the  con- 
test, when  he  reduces  the  water  ingested  to  a  minimum. 

Bicycle  racers  entering  six  days'  contests  undergo  the  severest  kind 
of  muscular  strain  and  require  a  diet  rich  in  protein  and  energy. 
They  work  from  eighteen  and  a  half  to  twenty-one  hours  out  of  the 
twenty-four,  and  have  a  minimum  of  sleep.  They  take  most  of  their 
food  in  fluid  or  semisolid  form,  in  part  to  save  time  and  in  part 
because  it  is  easily  digestible.  Water  is  not  drunk  during  the  race. 
A  dietetic  study  of  bicycle  racers  was  made  in  1898  in  New  York 
by  W.  0.  Atwater  and  H.  C.  Sherman.  The  most  remarkable  con- 
testants were  C.  W.  Miller,  who  rode  2007.4  miles  in  six  days, 'and 
F.  Albert,  who  rode  1822.6  miles.  Miller  lost  four  pounds  the  first 
day,  but  subsequently  maintained  his  average  weight.  His  average 
daily  food  consumption  in  grams  was:  Protein,  169;  carbohydrates, 
585 ;  fat,  181 ;  having  a  total  fuel  value  of  4,770  calories.  His  food 
was  of  very  simple  character,  and  pastry  and  pork,  as  well  as  alcohol 
and  tobacco,  were  excluded  during  a  month  of  training. 

Albert,  on  the  other  hand,  limited  his  diet  chiefly  by  the  exclu- 
sion of  veal  and  fat  meats.  He  smoked  tobacco  in  moderation  but 
did  not  use  alcohol.  He  lost  three  pounds  and  a  half  in  weight  on 
the  first  two  days  of  the  contest,  but  subsequently  regained  them. 
His  average  daily  food  consumption  in  grams  was:  Protein,  179; 
carbohydrates,  859;  fat,  198;  having  a  total  fuel  value  of  6,079  calo- 
ries. The  protein  metabolized  by  these  two  contestants  was  found 
to  be  about  twice  as  much  as  that  metabolized  by  the  average  me- 
chanic, and  they  did  more  than  two  days'  work  in  one.  Each  con- 
testant lost  "  body  protein  equivalent  to  two  or  three  pounds  of  lean 
flesh,  and  that  no  injury  resulted  therefrom  would  seem  to  indicate 
that  these  men  had  stores  of  protein  which  could  be  metabolized  to 
aid  in  meeting  the  demands  put  upon  the  body  by  the  severe  exer- 
tion, without  robbing  any  of  the  working  parts,  and  at  the  same  time 
relieving  the  system  of  a  part  of  the  labor  of  digestion.  Possibly 
the  ability  to  carry  such  a  store  of  available  protein  is  one  of  the  fac- 
tors which  make  for  physical  endurance"  (Atwater  and  Sherman). 


DIET   AXD  OCCUPATION  817 

The  dietetic  training  of  jockeys  is  merely  for  the  purpose  of  re- 
ducing weight  without  regard  to  endurance,  and  more  depends  on 
their  eating  a  small  quantity  of  food  than  upon  its  restriction  in 
variety.  They  should  make  their  fare  chiefly  bread  and  meat,  and 
abstain  from  much  fluid. 

Chambers  points  out  that  men  who  have  brief  holidays  in  the 
country  often  fail  to  get  the  maximum  good  of  their  outdoor  life, 
because  they  are  not  in  proper  condition  for  it.  If  a  shooting  or 
walking  trip  is  to  be  undertaken  for  a  week  or  two,  it  is  well  to  ab- 
stain for  a  fortnight  beforehand  from  eating  elaborate  dinners,  and 
to  leave  off  sweets  and  pastry  and  live  on  a  drier  diet  than  usual. 

In  general  the  athlete  in  training,  when  not  trying  to  reduce  his 
weight,  develops  more  energy  from  food  and  consumes  more  pro- 
tein than  the  ordinary  working  man.  In  the  case  of  the  crews  studied 
by  Atwater  this  excess  of  energy  equalled  400  calories,  or  10  per  cent, 
and  the  protein  consumption  was  increased  by  45  per  cent.  This  ex- 
cess of  protein  is  demanded  by  the  increased  nervous  tension  which  is 
lacking  in  the  slow,  methodical,  muscular  exertion  of  the  day  laborer. 

DIET  AND  OCCUPATION 

There  are  some  occupations  which  are  more  or  less  closely  con- 
nected with  dietetics.  Workers  in  lead,  plumbers,  painters,  polish- 
ers, pottery  glaziers,  et  aL,  should  be  taught  to  be  very  careful  to 
cleanse  the  clothing,  hands,  and  especially  their  finger  nails,  before 
eating.  The  soft  crumb  of  bread  getting  under  the  nails  easily  be- 
comes contaminated  with  lead  salts,  which  by  this  means  are  con- 
veyed to  the  stomach,  where  the  white-lead  carbonate,  which  is 
insoluble  in  water,  is  dissolved  by  the  gastric  juice  into  a  more  dan- 
gerous chloride.  Workers  in  dyestuffs,  artificial  flowers,  green  wall 
papers,  and  other  materials  in  which  arsenic  is  used,  should  be  simi- 
larly careful,  and  never  be  permitted  to  bring  their  food  into  the 
workrooms. 

Some  occupations  —  e.  g.,  those  of  foundrymen,  stokers,  and  porce- 
lain manufacturers  —  necessitate  exposure  to  extremely  high  tem- 
peratures. Profuse  sweating  results  and  thirst.  The  thirst  is 
quenched  by  subsequently  drinking  enormous  quantities  of  fluid, 
which  should  be  water  or  oatmeal  water,  not  too  cold,  rather  than 
beer  or  other  alcoholic  beverages.  Their  lives  at  best  are  liable  to  be 
shortened  by  the  suddenness  and  severity  of  the  changes  to  which  their 
kidneys  and  circulation  are  subjected,  and  a  resort  to  alcohol  is  soon 
fatal. 


818 


DIETARIES,   RATIONS 


Tea  tasters  acquire  more  or  less  poisoning,  although  they  do  not 
swallow  the  beverage,  for  a  good  deal  is  absorbed  by  the  mucous 
membrane  of  the  mouth.  The  symptoms  are  insomnia,  nightmare, 
headache,  "nervousness,"  tremors,  dyspepsia,  and  constipation  (see 
p.  250).  Even  smelling  the  tea  infusions  constantly  is  poisonous  to 
some  sensitive  persons  (Chambers).  To  mitigate  the  danger  they 
should  eat  abundantly  before  exposing  themselves  to  the  noxious  ef- 
fects of  their  occupation. 

Among  diseases  occasioned  by  the  handling  of  food  products  may 
be  mentioned  the  grocer's  itch,  from  handling  low  grades  of  sugar 
(now  much  less  common  than  formerly,  owing  to  better  methods  of 
refining),  and  the  bronchial  diseases  produced  by  the  inhalation  of 
flour  and  grain  dust  in  grist  mills  and  grain  elevators. 

There  are,  in  addition,  many  occupations  which  directly  interfere 
with  the  proper  digestion  of  food,  such  as  those  of  tailors  and  shoe- 
makers, whose  cramped  positions  compress  the  abdominal  viscera 
and  impede  full  respiratory  action.  Their  discomfort  from  dyspepsia 
and  flatulency  teaches  them  to  avoid  eating  vegetables  and  sweets. 

All  occupations  conducted  in  close,  ill-ventilated  apartments  are 
injurious  by  depriving  the  system  of  sufficient  oxygen  to  consume  the 
food  ingested. 

The  following  Table,  compiled  by  A.  P.  Bryant  for  the  Yearbook  of  the  "U.  8. 
Department  of  Agriculture  for  1898,  presents  a  Comparison  of  the  Aver- 
age Food  Consumption  of  People  of  Different  Occupations  or  in  Different 
Conditions  of  Life 

(Per  man  per  day) 


FAMILIES  STUDIED. 

Cost. 

Pro- 
tein. 

Fat 

Carbo- 
hy- 
drates. 

Fuel 
value. 

Cts. 

Gms. 

Gms. 

Gms. 

Cals. 

Average  <                     is  i   families  1  FOO(J  purchased. 

101 

136 

483 

3,655 

in      eimont,  Connecticut,  and  pFoO(j  eaten 

97 

130 

467 

3,515 

Average  of   14  mechanics'  fam-  "|  -™  ~  •,            ,        -, 

ilies  in  Connecticut,  New  Jer-  LIH    P1£cha9e(L 
m                       j  T   j  •           I  -c  ooa  eaten   .... 
sey,  lennessee,  and  Indiana.  J 

19 

110 

103 

161 
150 

425 

402 

3,690 
3,465 

Average     of      14      professional  "1 

men's  families  in  Connecticut  1  Food    purchased. 

108 

132 

429 

3,435 

Pennsylvania,     Indiana,    and  f  Food  eaten   .... 

28 

104 

125 

.423 

3,325 

Illinois    1 

Average  of   15  college  clubs  inl  Food    purchased. 
Maine,    Connecticut,    Tennes-  fFoO(j  eaten 

130 
107 

187 
148 

519 
459 

4,390 
3  690 

see,  and  Missouri    } 

f  Food    purchased. 
Average  of  above  3  3  studies   .  .  \  Food  £ten 

•• 

113 

103 

156 

138 

463 
436 

3,810 
3  500 

Average  of   12  labourers'  fami-  1  Food    purchased. 

103 

119 

356 

2,950 

lies  in  New  York  city   f  Food  eaten   .... 

19 

101 

116 

344 

2,905 

Average  of  1  1   poor  families  in  \  Food    purchased. 

96 

98 

414 

3,005 

New  York  citv   f  Food  eaten    .... 

15 

93 

95 

407 

2,915 

DIET   AND   OCCUPATION 


819 


FAMILIES  STUDIED. 

Cost. 

Pro- 
tein 

Fats. 

Carbo- 
hy- 
drates. 

Fuel 
Value. 

Cts. 

Cms. 

Cms. 

Cms. 

Cats. 

l~  1  Food    purchased. 

81 

98 

311 

2,525 

ie&,  very  ]  >or,  n                  g,  rpOO(j  eaten   .... 

ii 

80 

95 

308 

2,485 

Average  of   2    labourers'   famiOFood    purchased 

121 

148 

534 

4,055 

cumstances,  in  Pittsburg,  Pa.  J 

19 

120 

147 

534 

4,045 

Average  of  12  negro  families  in  t  ,,,     , 
Alabama     ....    j  Food   Purchased. 

9 

67 

134 

453 

3,375 

^CMcaeo     111  &                              f  Food   purchased. 

16 

103 

111 

391 

3,060 

Average  of  5  French  Canadian  i  ,_,     , 
families  in  Chicago,  111  )  Food   Purchased. 

22 

118 

158 

345 

3,365 

Average  of  4  families  of  Rus-  I  „      , 
sian  Jews  in  Chicago,  111.   .  .  )  Food   Purchased. 

19 

120 

101 

406 

3,095 

Average   of   8   Bohemian   fami-  1 
lies  in  Chicago,  111  )  Food   purchased. 

12 

115 

101 

360 

2,885 

Diet  for  Brain  Workers 

Persons  constantly  employed  in  mental  labor,  and  consequently 
leading  sedentary  lives,  usually  find  from  experience,  sooner  or  later, 
that  they  must  pay  attention  to  their  diet  in  order  to  maintain  the 
best  condition  of  health.  Energy  is  diverted  for  mental  work  at 
the  expense  of  digestive  activity,  consequently  it  is  important  that  the 
meals  should  be  of  such  a  character  as  not  to  unduly  tax  the  stomach 
and  intestines.  As  a  rule,  meat  should  be  eaten  only  once  a  day,  and 
then  only  in  moderation,  and  persons  who  are  not  of  strong  physique 
do  well  to  replace  meat  for  a  time  by  other  varieties  of  animal  food 
which  require  less  time  and  energy  for  their  digestion.  Milk,  eggs, 
fresh  fish  and  abundant  fresh  fruit,  with  light,  porous  and  dry  bread, 
should  constitute  their  staple  dietary. 

Brain  workers  may  suffer  from  lithaBmia,  which  is  undoubtedly 
often  due  to  other  causes  than  dietetic  errors,  such  as  anxiety,  worry, 
and  overwork.  Patients  of  this  class  do  better  with  a  good,  full, 
nourishing  diet,  largely  vegetarian,  provided  their  food  is  thoroughly 
well  cooked  and  is  light  and  digestible.  They  may  follow  the  dietary 
for  Lithaemia  given  on  page  560. 

The  brain  contains  nearly  three  times  as  much  fat  as  the  muscles, 
and  in  nerves  a  yet  larger  percentage  is  present.  For  this  reason  carbo- 
hydrates and  fats  are  of  value  for  brain  workers,  and  the  latter  food 
may  be  supplied  in  the  form  of  cream,  butter,  or  fat  well-cooked 
bacon. 

It  is  believed  by  some  writers  that  the  fact  that  fat  is  good  food 
for  brain  workers  depends  upon  the  ease  with  which  it  develops  energy 
with  less  complex  metabolism  than  starches,  and  the  nervous  energy 


820 


DIETARIES,   RATIONS 


of  many  Americans  is  sometimes  attributed  to  the  greater  consump- 
tion of  fat  in  this  country  as  compared  with  Continental  Europe  and 
England. 

The  popular  idea  that  fish  has  some  specific  action  as  a  brain  food 
on  account  of  the  phosphorus  which  is  present  in  some  species  in 
considerable  amount,  and  which  is  also  an  ingredient  of  nerve  tissue, 
is  not  founded  upon  fact.  Fresh  fish  is  very  wholesome,  and  by 
replacing  meat  in  the  menu  less  labor  is  required  of  the  digestive 
organs,  and  some  forms  of  fish  contain  abundant  fat  or  oil,  but  aside 
from  this,  fish  cannot  be  said  to  be  especially  a  brain  food.  It  has 
been  pointed  out  elsewhere  (p.  358)  that  the  tribes  of  man  who  live 
mainly  upon  fish  are  by  no  means  noted  for  their  intellectual  develop- 
ment. 

For  brain  workers  who  desire  to  keep  in  health  the  alternative  is 
either  to  take  at  least  two  hours  of  rest  after  a  noon  dinner  or  else  to 
eat  a  light  meal  at  noon  and  dine  later  in  the  day.  This  fact  should 
be  recognized  in  the  arrangement  of  meals  for  college  students.  It 
is  far  better  during  the  active  hours  of  brain  work  to  supply  only  such 
food  as  is  necessary  for  prompt  force  production  without  calling  upon 
•the  digestive  organs  for  the  expenditure  of  much  energy  in  elaborat- 
ing food  which  is  only  needed  for  storage. 

Breakfast  should  consist  of  fresh  fruit,  a  cereal  with  cream,  a 
poached  egg,  a  bit  of  broiled  (not  fried)  fresh  fish,  or  a  rasher  of 
bacon,  with  tea,  coffee,  or  cocoa. 

Luncheon  may  comprise  such  articles  as  a  roast  potato  with  butter 
and  cream,  or  beans  and  bacon,  one  or  two  light  sandwiches  made 
with  a  slice  of  game  or  a  relish  of  some  sort,  cheese,  lettuce  or  salad, 
and  a  baked  apple  and  cream. 

Dinner  should  be  a  hearty  meal  with  soup,  a  roast  or  joint,  vege- 
tables, and  a  light  farinaceous  pudding.  If  evening  work  must  be 
done,  there  should  be  an  interval  of  at  least  an  hour  for  rest  and 
recreation. 

A  Work  Ration  for  a  Professional  or  Literary  Man 
(Mrs.  E.  H.  Richards) 


Ounces. 

Pro- 
tein. 

Fats. 

Carbo- 
hydrates. 

Calories. 

Bread    

16 

Grains. 

32.0 

Grams. 

3.0 

Grams. 
258  0 

1216  6 

Meat      

16 

50  0 

30  0 

481  0 

Butter   

1 

25  0 

230  0 

ISuLiar    

4 

110  0 

451  0 

Milk    

8 

18  0 

18  0 

22  0 

329  6 

Oysters   

4 

7  0 

1  0 

37  8 

DIET   AND  OCCUPATION 


821 


Ounces. 

Pro- 
tein- 

Fats. 

Carbo- 
hydrates. 

Calories. 

Soup   

4 

Gtams. 
4.0 

Grams. 
3  0 

Grams. 

44.0 

Potatoes   

6 

3.0 

38  0 

168  1 

Eargs    . 

3 

10.0 

9  0 

123  8 

Oatmeal    

2 

1  0 

0  5 

4  0 

25  1 

1 

1.5 

6  5 

1.0 

70  1 

Fruit  

8 

0  5 

50  0 

207  1 

Additional  liquid  —  tea,  coffee  or  water 

30 

Total  

127  0 

96  0 

483  0 

3,384.2 

Overeating  should  studiously  be  avoided.  Loading  the  system 
with  incompletely  assimilated  food  products  impairs  intellectual  ac- 
tivity and  exhausts  the  nervous  system.  If  some  special  task  requires 
long  hours  of  work  and  absorbing  concentration,  it  may  be  better  to 
eat  but  little  at  a  time,  and  take  one  or  two  extra  lunches  during  the 
day.  When  such  labor  proves  fatiguing,  alcohol  may  be  temporarily 
employed,  but  only  with  meals,  and  not  as  a  stimulant  between. 
The  quantity  may  be  regulated  somewhat  by  the  appetite,  but  it 
should  never  be  large.  If  a  glass  or  two  of  claret  or  Burgundy  or  of 
malt  liquor  with  lunch  or  dinner  improves  the  appetite  for  solid  food 
and  aids  its  digestion,  it  is  beneficial,  for,  as  Chambers  wrote,  "  it 
stays  the  weariness  of  the  system  and  allows  the  nerve  force  to  be 
diverted  to  the  digestion  of  the  meal,"  but  to  labor  on  and  "  continue 
to  take  this  anaesthetic  between  meals  is  inconsistent " ;  and  "  when 
any  extraordinary  mental  toil  is  temporarily  imposed,  extreme  tem- 
perance or  even  total  abstinence  should  be  the  rule,  for  mental  activity 
makes  the  brain  bear  less  alcohol  than  rest  and  relaxation."  The 
varieties  of  beverages  named  are  all  better  than  port,  sherry,  or  the 
stronger  liquors. 

It  is  a  mistake  to  suppose  that  violent  muscular  exercise  is  an  offset 
to  mental  strain.  Very  moderate  exercise  combined  with  abundant 
fresh  air  and  with  mental  diversion  and  relaxation  are  more  benefi- 
cial, and  do  not  add  physical  exhaustion  to  mental  fatigue  already 
present. 

Tobacco  and  coffee,  like  alcohol,  are  stimulants  which  are  useful 
in  such  cases  only  in  proportion  to  the  moderation  in  which  they  are 
employed. 

Tea  may  be  allowed  in  the  earlier  part  of  the  day  if  it  does  not 
cause  wakefulness. 

Following  is  the  dietary  at  the  Lake  Erie  College,  at  Painesville, 
Ohio,  for  ten  days  for  women  students: 


822  DIETARIES,   RATIONS 

DAILY  MENU 

Wednesday 
Dinner. —  Corned  beef,  mashed  potatoes,  turnips,  bread,  butter,  rice  pudding. 

Thursday 

Breakfast. —  Baked  apples,  hominy  grits,  creamed  dried  beef,  bread,  butter, 
milk,  coffee. 

Luncheon. —  Cheese,  pudding,  raspberry  jam,  bread,  butter,  milk,  tea. 
Dinner. —  Roast  beef,  potatoes,  parsnips,  bread,  butter,  chocolate  pudding. 

Friday 

Breakfast. —  Oranges,  wheat  breakfast  food,  corned-beef  hash,  corn  rolls, 
butter,  milk,  coffee. 

Luncheon. —  Oyster  stew,  wafers,  bananas,  bread,  butter,  tea. 

Dinner. —  Pot  roast,  potatoes,  beets,  bread,  butter,  brown  betty,  lemon  sauce. 

Saturday 

Breakfast. —  Wheat  breakfast  food,  bacon,  baked  potatoes,  bread,  butter, 
milk,  coffee. 

Luncheon. —  Beef  in  gravy,  pickles,  sauce,  milk,  bread,  butter,  tea. 

Dinner. —  Lamb  chops,  potatoes,  canned  peas,  bread,  butter,  cherry  tapioca, 
cream. 

Sunday 

Breakfast. —  Oranges,  wheat  breakfast  food,  fried  mush,  maple  sirup,  bread, 
butter,  milk,  coffee. 

Luncheon. —  At  evening  on  Sunday.  Stewed  apricots,  cake,  milk,  tea,  bread, 
butter. 

Dinner. —  Stewed  chicken,  mashed  potatoes,  cranberries,  bread,  butter,  cot- 
tage pudding,  hard  sauce. 

Monday 

Breakfast. —  Bananas,  wheat  breakfast  food,  rolls,  codfish  balls,  bread,  but- 
ter, milk,  coffee. 

Luncheon. —  Beet  salad,  raspberry  jam,  milk,  bread,  butter,  tea. 
Dinner. —  Hamburg  steak,  browned  potatoes,  squash,  bread  pudding. 

Tuesday 

Breakfast. —  Hominy  grits,  minced  lamb,  milk,  bread,  butter,  coffee. 
Luncheon. —  Pea  soup,  crackers,  bananas,  tea,  bread,  butter. 
Dinner. —  Roast  pork,  baked  sweet  potatoes,  cole-slaw,  bread,  butter,  dates. 

"Wednesday 

Breakfast. —  Bananas,  hominy  grits,  bacon,  potato  cakes,  bread,  butter,  milk, 
coffee. 

Luncheon. —  Baked  beans,  brown  bread,  pickles,  milk,  bread,  butter,  tea. 

Dinner. —  Roast  beef,  boiled  potatoes,  spinach,  bread,  butter,  boiled  rice, 
maple  sirup. 

Thursday 

Breakfast. —  Oranges,  wheat  breakfast  food,  meat  hash,  French  toast,  bread, 
butter,  milk,  coffee. 

Luncheon. —  Cheese,  gingerbread,  bread,  butter,  cocoa. 

Dinner. —  Beefsteak,  mashed  potatoes,  Lima  beans,  bread,  butter,  baked  po- 
tatoes. 

Friday 

Breakfast. —  Cream  of  wheat  breakfast  food,  creamed  beef,  rolls,  bread, 
butter,  milk,  coffee. 

Luncheon. —  Pea  soup,  croutons,  apple  butter,  bread,  butter,  tea. 

Dinner. —  Baked  ham,  catsup,  stewed  tomatoes,  potatoes,  -bread,  butter, 
fruit  custard. 


DIET  AND  OCCUPATION"  823 

Saturday 

Breakfast. —  Oranges,  wheat  breakfast  food,  beef  in  gravy,  bread,  butter, 
ttilk,  coffee. 

Luncheon. —  Boiled  rice,  stewed  prunes,  milk,  bread,  butter,  tea. 

Diet  in  Commercial  Life 

The  responsibilities  and  anxieties  of  active  business  life  at  times 
react  unfavorably  upon  digestion,  producing  dyspepsia,  headache, 
constipation,  and  biliousness.  As  a  rule,  there  are  few  patients  less 
willing  to  listen  to  advice  in  regard  to  diet  and  habits  of  life  than  the 
overworked  business  man  engaged  in  the  strife  of  active  competition 
and  with  large  financial  interests  at  stake.  He  expects  a  dinner  pill 
or  laxative  or  the  latest  fashionable  "  tonic  "  to  counteract  the  per- 
sistent violation  of  the  simplest  dietetic  and  hygienic  laws,  and,  ob- 
taining temporary  relief,  goes  on  overtaxing  his  alimentary  canal, 
liver,  and  nervous  system,  laying  the  foundation  of  more  serious  ills, 
such  as  lithaemia,  arteriosclerosis,  or  possibly  gout,  gravel,  or  cirrhosis. 
The  prevalence  of  chronic  Bright's  disease,  arteriosclerosis,  diabetes, 
and  neurasthenia  in  this  country  is  in  part  attributable  to  such  fac- 
tors. Imperfectly  oxidized  waste  materials  in  the  circulation  may 
irritate  kidneys  and  vascular  system  alike,  and  long-continued  over- 
stimulation  eventually  results  in  structural  changes. 

While  prescribing  remedies  for  individual  symptoms  the  physi- 
cian should  not  neglect  to  give  wholesome  counsel  concerning  diet, 
and  such  advice,  however  little  heeded  by  itself,  will  sometimes  be 
regarded  as  an  essential  part  of  other  remedial  measures,  and  ac- 
cepted accordingly.  The  too  hasty  consumption  of  food,  the  neglect 
of  securing  proper  action  of  the  bowels,  and  carrying  the  concerns 
and  worries  of  the  counting-house  to  the  table,  combined  with  loss  of 
sleep  and  of  outdoor  exercise,  are  the  principal  difficulties  which  beset 
this  class  of  patients.  Three  good  meals  a  day  should  be  eaten.  The 
breakfast  should  be  substantial,  comprising  meat  or  eggs  or  fish  with 
some  cereal  and  fresh  fruit ;  and  dinner  should  be  the  last  meal  of  the 
day,  eaten  preferably  late  —  seven  o'clock  —  allowing  an  interval 
before  the  meal  for  recreation  or  diversion. 

The  luncheon  should  be  the  lightest  meal  of  the  day,  for  the  reason 
that  it  is  difficult  for  many  to  take  it  always  at  a  fixed  hour,  and  still 
more  difficult  to  allow  sufficient  time  for  due  mastication  and  diges- 
tion. Sydney  Smith  said,  referring  to  the  bad  habit  of  hasty  eating, 
that  "many  a  man  digs  his  grave  with  his  teeth."  It  is  neither 
necessary,  nor  advisable  to  eat  meat  three  times  a  day,  and  many  of 
these  patients  who  are  made  dyspeptic  by  eating  meat  and  vegetables 
together  find  that  they  have  less  flatulence  and  discomfort  after  meals 


824  DIETARIES,   RATIONS 

if  they  take  these  classes  of  foods  independently,  eating  meat  and 
no  vegetables  or  sugars  at  one  meal,  and  vegetables  without  meat  at 
another.  The  reason  for  this  should  be  explained  to  them  —  namely, 
that  carbohydrates,  digested  only  by  alkaline  saliva  and  pancreatic 
fluid,  may  interfere  with  the  acid  digestion  of  animal  food  in  the 
stomach.  The  luncheon  should  consist,  therefore,  of  simple  fari- 
naceous food  with  one  or  two  plainly  cooked  vegetables,  a  poached  egg, 
or  a  salad  and  a  relish  of  some  sort. 

Alcoholic  stimulants  of  any  kind  are  not  required,  except  to  coun- 
teract exceptional  fatigue,  and,  as  a  rule,  these  patients  are  better 
without  their  habitual  use.  If  allowed,  they  should  be  drunk  at 
dinner  only.  Malt  liquors  taken  at  luncheon  may  cause  drowsiness 
and  dullness  in  the  afternoon. 

As  adjuncts  to  the  dietetic  treatment  other  measures  should  not 
be'  neglected.  Cold  bathing  with  vigorous  rubbing  is  desirable  on 
rising,  and  an  occasional  Turkish  or  electric  light  bath  may  be  service- 
able if  there  is  a  tendency  to  heavily  loaded  urine  and  biliousness. 
Exercise  in  the  open  air  is  very  important.  Golfing  is  of  value,  but 
too  much  walking  is  fatiguing.  Bicycling  furnishes  more  active  ex- 
ercise and  diverts  the  mind;  but  horseback  riding  is  preferable,  even 
if  it  can  be  indulged  in  only  once  a  week.  Boxing,  fencing  and 
the  use  of  the  punch  bag  and  Indian  clubs  are  good  exercise  for 
this  type  of  patient. 

The  bowels  should  be  kept  active,  and  fresh  fruit  and  abundant 
draughts  of  pure  water  are  the  best  means  for  this  purpose. 

Diet  and  Travel 

In  traveling  one  is  often  placed  in  circumstances  in  which  it  is 
difficult  or  impossible  to  obtain  wholesome  food,  but  must  either  be 
content  with  badly  cooked  or  positively  repugnant  food,  or  go  with- 
out. Under  such  conditions  it  is  a  decided  advantage  to  have  a 
varied  taste,  so  that  something  may  be  found  which  will  not  disgust. 

It  is  difficult  to  give  any  but  the  most  general  directions,  for 
circumstances  which  are  so  various.  It  is  a  common  fault  to  eat  too 
much  when  traveling,  and  the  lack  of  exercise  combined  with  an 
excess  of  food  results  in  indigestion,  constipation,  and  biliousness. 
Sea  voyages  sometimes  benefit  invalids  and  dyspeptics  more  than 
the  healthy,  for  the  latter,  if  not  seasick  at  first,  often  overeat,  and 
suffer  in  consequence. 

The  "  stand-up  lunch  counters "  of  American  railway  stations 
freighted  with  doughnuts,  tough  ham,  and  pie  are  a  constant  invi- 
tation to  dyspepsia  with  the  hurried  eating  of  such  indigestible  arti- 


DIET  IN   PREGNANCY  825 

cles  as  they  afford,  but  which  the  more  general  introduction  of  dining 
cars  is  fortunately  replacing,  at  least  for  those  whose  means  allow 
them  to  consult  the  best  interests  of  their  digestive  organs. 

In  warm  climates  olive  oil  may  be  often  obtained  and  made  to 
replace  rancid  butter  upon  baked  potatoes.  Much  garlic  may  cause 
diarrhoea  and  colic  in  those  unaccustomed  to  its.  use,  but  mustard 
will  counteract  its  effect.  Lemon  juice  also  forms  a  wholesome 
relish  and  aids  in  checking  diarrhoea.  It  is  well  to  avoid  raw  or 
imperfectly  cooked  ham  and  sausage  of  every  sort,  for  fear  of  para- 
sitic infection.  If  the  food  is  greasy  its  digestion  may  be  promoted 
by  the  use  of  condiments,  such  as  vinegar,  Cayenne,  or  lemon  juice. 
All  milk  as  well  as  water  drunk  should  be  previously  boiled. 

Fresh  fruits,  crackers,  bread,  cold  meats,  soft-cooked  eggs,  and 
milk  will  be  found  to  comprise  digestible  articles  for  a  railway 
journey,  and  invalids  or  travelers  who  have  wandered  far  from  good 
food  supplies  do  well  to  carry  some  of  the  concentrated  preparations 
which  with  the  aid  of  a  little  hot  water  may  be  made  into  a  nutritious 
beverage,  such,  for  example,  as  malted  milk  and  cereals,  beef  meal  or 
beef  jelly,  chocolate,  condensed  coffee,  meat  extracts,  etc.,  besides 
which  there  is  an  almost  inexhaustible  variety  of  canned  foods,  meats, 
vegetables,  and  fruits  from  which  the  traveler  or  explorer  may  re- 
plenish his  table.  For  infants  sterilized  milk  may  be  carried  which 
will  keep  fresh  for  a  week,  or  canned  milk  may  be  provided  for  a 
longer  period. 

Lime  tablets  are  prepared  which  may  be  conveniently  used  in 
traveling  when  fresh  lime  water  is  likely  to  be  required  for  dilution 
of  milk  or  for  use  in  seasickness. 

DIET  IN  PREGNANCY 

It  is  not  customary  to  adopt  any  definite  system  of  diet  for  preg- 
nancy unless  complications  arise.  If  serious  vomiting  occurs  in  the 
early  months,  this  should  be  treated  in  the  manner  described  on 
p.  603.  If  albuminuria  is  discovered,  meat  and  other  proteid  food 
must  be  restricted,  in  accordance  with  the  directions  given  under 
albuminuria  (p.  555).  If  the  patient  becomes  very  anaemic,  without 
albuminuria,  meat,  eggs,  and  milk  should  be  eaten  in  abundance 
(p.  542). 

The  "  longings "  of  pregnant  women  for  various  indigestible  ar- 
ticles, such  as  pickles,  chalk,  etc.,  are  largely  mythical,  and  occur, 
if  at  all,  only  as  an  accompaniment  of  a  general  hysterical  con- 
dition, not  as  a  peculiarity  of  the  period  of  pregnancy.  Pregnant 


826  DIETARIES,   RATIONS 

women,  however,  should  live  simply  and  avoid  foods  which  are  likely 
to  produce  dyspepsia,  heartburn,  and  colic,  such  as  sweets,  pastry, 
fried  food,  rich  sauces,  salads,  crustaceans,  spiced  dishes,  and  heating 
drinks.  They  often  suffer  from  constipation,  in  which  case  fruits  and 
coarse  cereals,  such  as  oatmeal  or  wheaten  grits,  may  be  of  service 
(p.  636).  The  stomach,  especially  at  night,  should  not  be  overloaded. 

The  idea  formerly  prevalent  that  pregnant  women  need  to  eat 
food  containing  abundant  phosphates  and  lime  salts,  to  furnish  the 
embryo  with  material  for  making  bones,  as  a  hen  eats  lime  to  make 
egg  shells,  is  no  longer  accepted.  The  salts  in  question  are  suffi- 
ciently contained  in  an  ordinary  mixed  diet,  such  as  any  pregnant 
woman  may  eat,  if  plainly  cooked. 

Another  theory,  equally  ingenious  and  directly  opposed  to  the 
one  above  mentioned,  is  only  interesting  historically,  for  efforts  to 
aid  Nature  in  a  process  which  she  is  abundantly  competent  to  regu- 
late unaided  are  now  regarded  as  futile.  This  theory  was  that  the 
agonies  of  labor  would  be  less  severe  if  the  pregnant  woman  lived 
upon  a  diet  of  fruits  and  meats,  avoiding  bread  and  fresh  vegetables 
during  gestation,  on  the  ground  that  the  lime  salts  which  the  latter 
contain  would  favor  early  ossification  of  the  infant's  bones,  and  thus 
make  the  labor  proportionately  difficult. 

It  will  be  observed  that  the  first  theory  favors  the  child,  and 
the  second  the  mother,  but  practically  it  has  been  found  that  diet 
has  little  or  no  influence  either  way,  so  long  as  it  is  digestible, 
nourishing,  and  sufficient  to  keep  the  mother  in  good  general  con- 
dition. 

DIET  FOR  PUERPERAL  WOMEN 

Within  the  past  generation  a  revolution  has  been  experienced  in 
the  dietetic  treatment  of  puerperal  women,  and  they  are  no  longer, 
as  formerly,  placed  for  ten  days  or  a  fortnight  upon  a  diet  of  toast 
water,  "  slops,"  etc.,  with  the  idea  that  semistarvation  would  keep 
off  puerperal  fever  and  "  milk  fever."  This  change  is  largely  due 
to  methods  of  antiseptic  midwifery,  but  the  reaction  started  even 
earlier,  and  in  1876  the  late  Fordyce  Barker  of  New  York,  who  was 
one  of  the  first  to  forsake  the  old  routine,  wrote  of  the  puerperal 
state :  "  I  have  never  seen  the  slightest  evil  result  from  good,  ample, 
judicious  alimentation,"  and  "  I  have  had  patients  eat  a  good  piece  of 
tenderloin  steak  the  day  after  labor  with  a  relish,  and  with  happy 
results." 

A  pregnant  woman  may  eat  her  ordinary  diet  up  to  the  com- 
mencement of  labor.  If  the  labor  be  greatly  protracted,  the  first 


DIET  FOR  PUERPERAL   WOMEN  827 

stage  lasting,  as  it  exceptionally  does,  for  more  than  a  few  hours,  it 
will  not  do  to  let  her  strength  become  further  exhausted  from  lack  of 
food,  and  she  should  be  urged  to  take  stimulating  hot  broths,  gruels, 
or  similar  easily  digested  food.  Under  the  circumstances  she  is 
naturally  nervous  and  may  decline  all  food,  so  she  should  be  given 
only  that  which  is  quickly  swallowed  without  effort.  In  ordinary 
cases,  however,  no  food  is  necessary  or  desirable  during  labor. 

Immediately  after  delivery  the  woman,  exhausted  by  muscular 
effort  and  agonizing  pain,  and  possibly  also  under  the  influence  still 
of  an  anaesthetic,  needs  rest  rather  than  food,  and  as  she  is  more 
thirsty  than  hungry,  she  may  drink  freely  of  water  or  Vichy. 

On  the  other  hand,  many  puerperal  complications,  including 
mania,  are  favored  by  exhaustion  and  inanition,  and  good  feeding 
should  not  be  delayed  too  long.  The  nursing  woman,  moreover, 
needs  a  more  liberal  diet  than  do  other  patients.  Her  milk  contains 
a  large  percentage  of  proteid  and  fat,  and  she  also  loses  proteid  sub- 
stance to  a  greater  or  less  extent  through  the  lochia.  A  low  diet 
means  poor  breast  milk,  for  it  diminishes  both  the  milk  fats  and 
proteids. 

Spiegelberg  says :  "  It  is  a  bad  practice  to  allow  healthy  lying-in 
women  to  fast  long;  they  need  to  be  well  fed,  and  if  the  appetite 
is  good  they  may  be  encouraged  to  eat."  If  they  are  well  nourished 
they  both  sleep  and  feel  better.  "Four  or  five  hours  after  con- 
finement the  patient  may  be  given  a  cup  of  hot  bouillon  or  chicken 
or  mutton  broth.  She  usually  does  not  care  for  meat  before  the 
second  or  third  day,  but  she  may  have  it  then.  Meanwhile  she  is 
allowed  broths  of  any  kind,  thickened  with  egg  or  rice,  milk,  tea, 
light  farinaceous  gruels  or  puddings,  soft-cooked  eggs,  toast,  milk 
toast,  custards."  Schroder  gives  meat  and  vegetables  within  a  day 
or  two  after  the  conclusion  of  labor.  Lusk  recommended  a  light 
fluid  or  semisolid  diet  for  the  first  three  days.  Then,  after  the  bowels 
have  moved  once  or  twice  and  the  appetite  returns,  steak,  chops, 
a  piece  of  fowl  or  a  bird,  eggs,  and  cooked  fruits  are  given. 

Playfair  adopted  the  following  system:  If  the  woman  is  confined 
in  the  early  morning  hours,  at  9  A.  M.  she  is  given  a  cup  of  tea  and 
a  piece  of  toast;  at  1  P.  M.  a  light  lunch  of  some  form  of  predi- 
gested  meat  preparation;  at  5  p.  M.  tea  or  beef  tea,  and  at  7  P.  M.  a 
small  bit  of  chicken  with  bread  and  butter  or  milk  toast.  Tea  again 
at  9  P.  M.  He  discountenanced  a  continued  use  of  gruels,  "slops," 
and  stimulants.  During  the  next  day  or  two  if  the  patient  is  hungry, 
she  is  allowed  sweetbread,  chicken,  fish,  eggs,  and  milk. 

On  the  whole,  the  patient's  appetite  is  a  better  guide  for  feeding 


828  DIETARIES,   RATIONS 

than  are  any  rules  as  to  the  exact  time  which  has  elapsed  since 
parturition.  She  should  not  be  urged  to  take  food,  unless  greatly 
exhausted,  and  the  stomach  must  not  be  overloaded;  but  if  hungry 
after  the  establishment  of  the  milk  secretion  and  after  free  action  of 
the  bowels,  she  may  take  a  reasonable  quantity  and  variety,  though 
while  still  in  bed  she  needs  less  than  if  up  and  about.  The  occur- 
rence of  fever  is  a  contraindication  for  giving  much  proteid  food  ex- 
cept milk,  but  extreme  exhaustion  without  febrile  reaction  demands  it. 

SELECTION  OF  A  WET  NURSE 

The  selection  of  a  wet  nurse  should  be  based  upon  the  following 
data: 

Her  own  general  health  and  digestion  should  be  good,  and  her 
bowels  not  habitually  constipated.  All  evidence  of  syphilis,  tubercu- 
losis, or  other  disease  should  be  excluded  strictly.  A  primipara  is  to 
be  preferred  to  a  multipara  as  having  milk  somewhat  richer  in  fat. 
Her  best  age  is  between  twenty-two  and  thirty  years,  and  she  should 
be  of  good  temper  and  have  cleanly  habits.  Her  period  of  lactation 
should  not  be  too  widely  different  from  the  age  of  the  infant  to  be 
nursed.  The  breasts  should  be  firm,  and  the  nipples  fairly  prominent 
and  free  from  fissures.  Breasts  which  are  always  oozing  spontane- 
ously are  by  no  means  always  the  best,  for  their  milk  is  soon  ex- 
hausted. 

The  nurse's  own  child,  if  living,  should  be  examined,  for  if  it  has 
been  nursing  at  the  breast  its  condition  is  a  better  index  of  suitable- 
ness of  the  mother's  milk  than  her  own  appearance.  The  child 
should  be  in  good  flesh  and  firm,  without  evidence  of  gastric  catarrh, 
fever,  eruptions,  or  indigestion,  and  of  good  development  for  its  age. 

The  question  whether  it  is  possible  for  a  wet  nurse  to  transmit 
her  own  mental  and  physical  characteristics  to  the  child  at  her 
breast  has  given  rise  to  much  discussion,  but  there  is  no  more  reason 
why  she  should  transmit  an  evil  temper  through  the  food  she  gives 
than  that  a  cow  should  transmit  a  bland  one.  An  ill-tempered,  iras- 
cible wet  nurse  may  sometimes  give  milk  which  disagrees  with  the 
child's  stomach,  but  beyond  that  there  is  nothing  in  the  belief  that 
she  can  affect  it  mentally  or  morally  by  this  agency. 

The  milk  which  can  be  expressed  from  the  breast  should  have 
the  following  properties:  Reaction  amphoteric  or  faintly  alkaline  to 
litmus,  but  acid  to  phenophthalin,  color  an  opaque  blue-white,  specific 
gravity  1.031,  taste  sweetish.  Examined  microscopically,  the  fat 
corpuscles  should  abundantly  fill  the  field  and  be  of  nearly  equal  size. 


DIET   OF  A   NURSING  MOTHER  OR  WET   NURSE        829 

Human  breast  milk  on  an  average  has  a  specific  gravity  of  1.031 
at  70°  F.,  but  it  varies  between  1.017  and  1.036  (Holt).  The  fat 
varies  less  than  the  sugar  and  proteids. 

If  the  specific  gravity  of  the  milk  is  high,  and  at  the  same  time 
the  percentage  of  fat  is  considerable,  the  gravity  must  be  due  to  a 
larger  quantity  of  proteids  than  usual,  because  fat  tends  to  lower  it. 
If  the  fat  percentage  is  small  and  the  specific  gravity  of  the  milk  is 
low,  the  proteids  must  also  be  reduced.  Holt  furnishes  the  following 
convenient  table  for  determining  the  richness  of  human  milk  in  fats 
and  proteids,  which  gives  results  that  are  sufficient  for  practical  pur- 
poses in  examining  the  milk  of  a  wet  nurse: 


Specific  gravity 
70°  F. 

Cream—  24  hours. 

Proteids  —  (calculated). 

Normal  average   .  . 

1.031 

7% 

1.5% 

Healthy  variations 

1.028  —  1.029 

8%—  12% 

Normal    (  rich  milk  )  . 

<(     '            « 

1.032  —  1.033 

5%—  6% 

"           (fair  milk). 

Unhealthy      " 

Below  1.028 

High    (above    10%). 

"     or  slightly  below. 

«               <( 

"          << 

Normal    (5%—  10%). 

Low. 

<<               tt 

n          n 

Low  (below  5%). 

Very    low     (very    poor 

milk). 

H                            (( 

Above  1.033 

High. 

Very    high    (very   rich 

milk). 

ft                            ft 

«                     (C 

Normal. 

High. 

(1                            ft                            (t                   « 

Low. 

Normal   (  or  nearly'  so  )  . 

To  calculate  the  actual  fat  from  the  cream  multiply  by  three- 
fifths. 

In  examining  the  composition  of  the  milk  of  a  wet  nurse  it  is 
only  fair  to  the  nurse  to  remember  that,  like  cow's  milk,  her  own 
contains  less  fat  when  the  milk  is  first  drawn  than  after  the  breast 
has  been  nursed  for  a  few  moments.  The  quantity  of  the  milk  may 
be  estimated  by  weighing  the  infant  immediately  before  and  after 
suckling,  when  the  gain  should  be  between  three  and  six  ounces. 


DIET  OF  A  NURSING  MOTHER  OR  WET  NURSE 

If  half  the  care  bestowed  upon  cows  in  a  model  dairy  were  given  to 
the  period  of  lactation  in  women,  there  would  be  far  less  need  of 
artificial  feeding  of  infants. 

The  diet  of  the  nursing  mother  or  wet  nurse  should  be  regulated, 
to  prevent  noxious  substances  from  passing  into  the  breast  milk  and 
to  keep  her  in  good  health,  so  that  she  does  not  suffer  from  consti- 
pation, indigestion,  or  anaemia.  Her  weight  should  not  alter,  and 


830  DIETARIES,   RATIONS 

if  she  has  menstruated  once  or  twice  her  milk  changes  and  may  dis- 
agree. The  nipples  should  be  kept  in  good  condition. 

If  cow's  milk  does  not  make  the  mother  constipated  or  bilious  she 
may  drink  it  abundantly.  She  may  take  gruels  and  meat  broths, 
and  should  eat  simple  nourishing  food,  meat,  eggs,  vegetables,  and 
fruits.  The  latter,  even  if  sour,  do  not  react  unfavorably  upon  the 
child,  provided  the  mother's  digestion  is  good,  and  they  serve  to  keep 
the  child's  bowels  active.  Thomas  S.  Southworth  especially  recom- 
mends the  taking  of  cocoa  and  thin  corn  meal  gruel  in  addition  to 
a  quart  of  milk  daily.  The  mother  should  forego  the  drinking  of 
much  tea  and  coffee.  Beer  and  wine  also  should  not  be  drunk  unless 
they  are  especially  prescribed  as  a  tonic.  Wet  nurses  often  demand 
beer,  ale,  or  porter  with  their  meals  if  they  have  been  accustomed  to 
it;  but  the  popular  idea  that  such  beverages  are  especially  beneficial 
is  fallacious.  Malt  liquor  sometimes  causes  the  secretion  of  more 
milk,  because  more  liquid  is  drunk,  but  the  milk  is  no  better  for  it. 
A  reasonable  quantity  of  liquids  should  be  drunk,  however,  or  the 
secretion  of  milk  will  suffer.  The  liquid  may  be  in  the  form  of  plain 
or  effervescing  water,  milk,  soups,  etc. 

The  mother  or  wet  nurse  should  avoid  all  fatigue,  worry,  and 
emotional  excitement  of  any  kind,  which  may  inhibit  her  digestive 
functions,  and  should  take  daily  outdoor  exercise. 

On  the  whole,  the  best  indication  for  the  dietetic  treatment  of 
the  nursing  mother  or  wet  nurse  is  the  study  of  the  condition  of 
the  child's  digestion,  bowels,  and  nutrition.  A  too  meager  diet  for 
the  nurse  is  soon  evident  in  lack  of  nutrition  and  development  of  the 
infant. 

Drugs  in  Human  Milk. —  Xot  many  drugs  pass  unchanged  into  the 
milk  which  are  likely  to  poison  the  child  through  its  food,  but  there 
are  some  which  should  be  carefully  avoided  on  this  account.  Such 
are  belladonna,  opium,  morphine,  and  other  alkaloids ;  iodine  and  its 
preparations;  mercury  and  its  salts;  salicylic  acid. 

When,  for  any  reason,  it  becomes  necessary  to  discontinue  the 
nursing  and  stop  further  secretion  of  milk,  the  diet  at  once  should 
be  made  as  dry  as  possible,  and  a  minimum  quantity  only  of  fluid  is 
allowed. 

THE  FEEDING  OF  INFANTS 

Size  of  the  Infant's  Stomach. —  With  regard  to  infant  nursing,  it 
is  never  sufficient  to  give  general  directions  about  an  infant's  food. 
The  physician  should  supervise  the  exact  mode  of  its  preparation, 
and  order  both  the  quantity  to  be  given  and  the  intervals  at  which  it 


THE  FEEDING   OF    INFANTS  831 

is  to.be  given.  Mothers  seldom  know  what  is  best  for  their  infants 
in  these  matters.  It  is  therefore  well  to  explain  to  them  fully  the 
facts  as  to  the  proper  hours  for  feeding  and  the  amount  of  food  re- 
quired, and  also  to  give  them  some  idea  of  the  size  of  the  infant 
stomach,  for  many  have  a  vague  idea  that  the  word  "  stomach  "  in- 
cludes the  entire  abdominal  cavity. 

Rotch  gives  the  following  table  of  capacities  of  infant  stomachs : 

1.  Premature  8  months'  infant 8  c.  c. 

2.  Infant     5  days  old     25-30      '       about  1  oz. 

3.  Infant     4  weeks  old    75      ' 

4.  Infant     8        "        "      96      ' 

5.  'Infant  16        "        "      107      '           "       3  ozs. 

6.  Infant  20        "        "      108      ' 

It  is  advisable  to  show  the  mother  or  nurse  an  empty  bottle  rep- 
resenting the  capacity  of  the  infant's  stomach,  in  order  to  impress 
upon  her  the  danger  of  overfeeding  it. 

Overfeeding. —  It  is  sometimes  said  that  overfeeding  kills  more 
babies  than  starvation,  and  certainly  it  is  responsible  for  a  large 
proportion  of  the  ailments  of  early  infancy,  such  as  gastric  catarrh 
and  diarrhoea.  This  is  especially  true  in  summer,  when  the  fretful- 
ness  of  the  child,  which  is  often  mistaken  for  hunger,  may  be  due  to 
thirst,  the  external  temperature,  too  warm  clothing,  or  indigestion. 
At  such  times  Holt  advises  reducing  the-  bulk  of  each  meal  by  one 
quarter  and  giving  the  infant  more  water  to  drink,  for,  as  he  says, 
infants,  like  adults,  require  less  food  in  excessively  hot  weather. 

It  is  difficult  to  impress  mothers  with  the  fact  that  milk  should 
never  be  given  to  soothe  a  baby's  f retf ulness  merely,  and  "  un- 
methodical and  improper  feeding  is  quite  as  bad  as  feeding  with 
improper  aliments"  (Adams). 

The  new-born  infant  secretes  ptyalin  only  from  the  parotid  glands. 
After  the  second  month  the  amylolytic  ferments  are  secreted  from 
other  glands,  namely,  the  submaxillary  and  the  pancreas.  Not  until 
the  sixth  month,  however,  or  the  period  of  teething,  are  these  fer- 
ments strong  enough  to  enable  the  infant  to  digest  large  quantities  of 
starch,  although  very  young  infants  may  digest  moderate  quantities 
of  dextrinized  cereals,  used  as  diluents  of  milk  to  prevent  formation 
of  large  curds.  Rennet  is  secreted  by  the  infant  stomach,  and  is  the 
first  secretion  to  act  upon  milk.  When  10  per  cent  of  lime  water  or 
two  grains  of  sodium  bicarbonate  to  the  ounce  of  milk  is  added  to 
the  feeding  mixture,  rennet  fails  to  act  in  this  medium,  and  the 
milk  remaining  uncoagulated,  passes  more  promptly  into  the  in- 
testine. 


832  DIETARIES,   RATIONS 

Methods  of  Feeding 

Infants  may  be  given  their  food  in  one  of  five  ways:  I.  As 
mother's  milk.  II.  As  milk  from  a  wet  nurse.  III.  By  bottle  feed- 
ing. IV.  By  mixed  feeding  —  i.  e.,  when  the  mother's  or  nurse's 
milk  is  supplemented  by  bottle  feeding.  V.  By  gavage. 

There  is  no  room  for  doubt  that  infants  brought  up  on  breast 
milk  are  stronger  and  better  able  to  remain  in  good  health  and 
resist  disease  than  those  who  are  hand  fed,  for  no  artificially  prepared 
infant  food  has  ever  been  devised  which  is  as  accurately  balanced  in 
its  various  ingredients  as  good  mother's  milk. 

This  method  is  unquestionably  better  for  the  infant  in  all  cases 
where  it  is  feasible  than  any  method  of  artificial  feeding.  In  lands 
without  cow's  milk,  such  as  Japan  or  the  arctic  regions,  infants  are 
singularly  free  from  digestive  disorders.  Artificial  feeding,  if  care- 
lessly performed,  is  full  of  dangers  to  the  infant.  Statistics  might  be 
cited  indefinitely,  showing  the  relative  high  mortality  rate  among 
artificially  fed  infants.  For  example:  in  Germany,  which  has  the 
second  highest  infant  mortality  of  Continental  Europe  (ranking  next 
to  Russia),  in  Berlin  during  the  quinquennium  from  1900  to  1904 
inclusive,  among  the  deaths  of  infants  under  one  year  of  age,  90 
per  cent  were  artificially  fed  —  and  only  10  per  cent  exclusively 
breast  fed.  In  Paris  the  same  ratio,  1 :  10,  obtains. 

I  AND  II. —  FEEDING  BY  THE  MOTHER  OE  WET  NURSE 

Louis  Starr  advises  putting  the  infant  to  the  breast  as  early  as  six 
or  eight  hours  after  labor  is  completed,  which  is  good  for  both  mother 
and  child.  For  the  mother  it  improves  the  nipple,  stimulates  the 
true  milk  secretion,  and  reflexly  the  uterine  contractions;  for  the 
infant  it  is  also  desirable,  for  it  insures  the  ingestion  of  colostrum. 

Colostrum  constitutes  the  mammary  secretion  of  the  first  three  days. 
This  secretion  is  mildly  laxative,  and  cleanses  the  child's  alimentary 
canal  of  the  waste  matter  called  meconium,  which  is  found  within  it 
at  birth. 

Colostrum  contains  an  excess  of  albumin,  so  that  boiling  coag- 
ulates it.  It  also  has  large  corpuscles,  which  may  be  seen  with  the 
microscope  throughout  the  first  week  of  lactation,  gradually  lessen- 
ing in  number.  They  then  rapidly  disappear,  and  none  should  be 
present  after  a  fortnight.  If  found  later,  the  milk  is  certain  to  dis- 
agree and  a  change  of  nurse  is  necessitated. 

Intervals  for  Feeding. —  Infants  during  the  first  three  days  should 
be  nursed  only  four  or  five  times  a  day.  Water  may  be  given,  but 


THE  FEEDING  OF   INFANTS  833 

no  bottle  food,  which  merely  disorders  the  stomach  and  lessens  the 
ability  to  suck.  After  this  period  once  every  two  hours  is  the  proper 
interval  for  suckling  for  the  first  six  weeks  or  two  months.  The 
child  should  be  fed  with  this  interval  between  5  A.  M.  and  11  p.  M., 
with  one  feeding  only  in  the  middle  of  the  night.  If  absolute  regu- 
larity is  always  observed  in  the  hours  for  nursing,  the  child's  digest- 
ive organs  keep  in  much  better  condition,  it  sleeps  better,  and  is 
much  less  likely  to  be  overfed.  During  the  first  four  or  five  months 
of  life  an  infant  should  be  fed  once  during  the  night;  after  that  it 
need  not  be  fed  between  10  p.  M.  and  7  A.  M.  When  a  year  old,  if 
strong  and  well,  it  need  not  be  fed  between  7  p.  M.  and  7  A.  M.  If 
fed  or  nursed  oftener  than  this,  the  child  receives  too  much  food,  and 
digestion  and  rest  are  both  disturbed. 

Sometimes  an  infant  will  demand  milk  at  night  and  not  take  it  in 
the  daytime  as  well  as  it  should,  but  with  a  little  firmness  and  by 
starving  it  for  a  few  hours  until  it  is  really  hungry,  it  may  be  trained 
to  suckle  in  the  manner  which  experience  has  proved  will  be  best 
for  both  itself  and  its  mother.  From  fifteen  to  twenty  minutes  is 
sufficient  time  to  keep  the  child  at  the  breast,  and  often  it  will  doze 
off  to  sleep  after  nursing. 

As  the  child  grows  older  the  intervals  between  the  hours  of  day 
nursing  are  to  be  prolonged,  in  accordance  with  the  tables  given  on 
pages  839-841,  and  the  child  may  be  allowed  to  remain  a  few 
moments  longer  at  the  breast. 

The  infant  while  sucking  should  always  be  held  in  a  comfortable 
position  with  the  nipple  within  easy  reach. 

After  a  three-hour  interval  for  feeding  has  been  reached,  it  may 
be  maintained  in  many  cases  until  lactation  is  completed,  but  after 
reaching  six  months  of  age  some  infants  do  better  with  a  three  and 
a  half  hour  or  four  hours'  interval. 

Infants  born  with  a  cleft  lip  or  palate  cannot  be  nursed  properly 
at  the  breast,  for  they  are  unable  to  make  the  necessary  vacuum  in 
the  mouth  to  draw  the  milk.  They  may  be  unable  to  take  the  bottle 
successfully,  and  must  then  be  fed  by  gavage  or  with  a  spoon. 

III. — FEEDING  BY   THE   BOTTLE 

When  it  becomes  necessary  to  employ  artificial  feeding,  the  prin- 
ciple involved  is  to  obtain  a  food  by  modifying  cow's  milk,  which 
food  shall  correspond  as  nearly  as  possible  to  the  composition  of  aver- 
age human  milk,  but  be  adapted  also  to  the  needs  of  the  par- 
ticular infant,  as  suggested  by  the  state  of  its  digestive  organs  and 

existing  nutrition  and  development. 
55 


834  DIETARIES,   RATIONS 

Due  regard  should  be  had,  of  course,  for  the  financial  condition 
of  those  for  whom  an  especially  modified  milk  is  ordered.  For  the 
very  poor,  milk  is  a  serious  item  of  expense,  and  cream  and  sugar 
may  be  out  of  the  question.  Condensed  milk  is  usually  cheaper  in 
large  cities  than  fresh  cow's  milk,  for  less  care  and  expense  is  involved 
in  its  transportation,  and  it  is  accordingly  much  used  by  the  poor. 
Moreover,  in  hot  weather  it  keeps  without  ice,  but  for  reasons  given 
elsewhere  (p.  108)  it  is  never  to  be  preferred  when  good  fresh  cow's 
milk  is  obtainable.  It  is  deficient  in  protein,  and  this  may  be  cor- 
rected by  adding  meat  broth,  beef  juice,  or  egg  albumen.  It  is  also 
deficient  in  fat,  and  cod-liver  oil  may  be  added,  if  cheaper  than  cream. 

Cow's  milk  contains  approximately  half  the  quantity  of  sugar 
present  in  human  milk.  Leeds  says  that  the  curd  derivable  from 
human  milk  is  only  one-fifth  as  much  as  that  of  cow's  milk,  and  there 
are  other  striking  differences  in  regard  to  the  quantity  of  casein  pre- 
cipitable  by  acid,  as  compared  with  the  non-coagulable  ingredients 
of  both  forms  of  milk.  (See  comparative  analyses  of  human  and 
cow's  milk,  p.  60.)  For  this  reason  cow's  milk  should  be  diluted  for 
very  young  infants,  in  order  to  bring  the  casein  nearer  to  the  human 
standard ;  but  the  addition  of  water  reduces  the  percentage  of  fat  and 
of  sugar,  which  therefore  must  be  provided  separately. 

Escherich  has  shown  that  the  infant  fed  upon  diluted  cow's  milk 
has  to  take  much  more  fluid  than  when  nursed  by  breast  milk  to  get 
the  same  quantity  of  nutriment,  with  consequent  distention  and  pos- 
sible enfeeblement  of  the  stomach. 

The  disproportion  of  fat  may  be  counterbalanced  by  using  "  top 
milk  "  —  i.  e.,  the  upper  layer  which  forms  after  the  milk  has  stood 
for  about  eight  hours,  and  which  contains  most  of  the  cream.  Milk 
sugar  is  then  to  be  added  in  the  proportion  of  one  heaping  teaspoon- 
ful  to  four  ounces  of  the  diluted  top  milk.  If  cane  sugar  is  used, 
which  is  less  desirable,  as  it  is  more  apt  to  ferment,  only  one  tea- 
spoonful  to  every  six  ounces  is  necessary. 

From  a  quart  of  ordinary  milk  six  ounces  of  top  milk  may  be 
skimmed,  seven  ounces  from  rich,  and  five  from  poor  milk.  In  lieu 
of  top  milk  a  mixture  of  equal  parts  of  cream  and  of  ordinary  milk 
should  be  used  (Holt). 

When  the  milk  causes  dyspepsia,  and  large  curds  are  vomited, 
it  is  well  to  substitute  barley  water  for  plain  water  in  the  same 
proportion  as  a  diluent. 

If  pearl  barley  is  used  it  should  be  boiled  a  long  time  —  for  six 
or  eight  hours  —  the  water  being  replaced  as  it  evaporates.  The 
proportion  usually  employed  is  two  tablespoonfuls  of  barley  to  the 


THE  FEEDING  OF   INFANTS  835 

quart  of  water.  After  careful  straining  through  a  linen  cloth,  a  pinch 
of  salt  is  added,  and  when  cool  the  fluid  is  ready  for  use.  Instead 
of  pearl  barley,  one  of  the  barley  flours  may  be  employed.  This 
answers  the  purpose  as  well,  and  has  the  advantage  of  requiring 
much  less  time,  boiling  for  half  an  hour  being  sufficient. 

Holt  gives  the  following  formulae  for  an  infant  two  months  old 
receiving  twenty-four  ounces  a  day : 

Top  milk    8  ounces. 

Barley    water    16       " 

Milk  sugar   6  heaping  teaspoonfuls,  or 

Cane  Sugar    4         "  " 

The  quantity  is  to  be  slightly  increased,  but  the  proportion  may 
remain  the  same  until  the  seventh  or  eighth  month,  when  the  mixture 
should  be  changed  gradually  to  — 

Top  milk    19  ounces. 

Barley  water   19       " 

Milk   sugar    9  teaspoonfuls,  or 

Cane  sugar    5 

In  answer  to  the  question,  "  Should  a  child  one  year  old  take  plain 
cow's  milk  ?  "  Holt  says :  "  Many  children  can,  but  the  majority  do 
better  when  the  milk  is  modified  by  the  addition  of  cream  and  water, 
or  by  the  use  of  diluted  top  milk.  After  standing  six  hours  six  ounces 
should  be  taken  off  from  the  top  of  the  milk  bottle  and  ten  ounces 
more  should  then  be  poured  off  and  the  two  mixed.  This  may  be 
diluted  with  an  equal  quantity  of  water  or  barley  water." 

It  is  generally  conceded  that  fresh  raw  cow's  milk  derived  from 
a  healthy  cow,  and  carefully  kept  from  germ  contamination,  is  a 
more  wholesome  food  for  babies  than  milk  which  is  either  sterilized, 
or  pasteurized.  But  in  cities  always,  and  everywhere  in  summer,  it  is 
difficult  or  impossible  to  obtain  such  milk,  and  one  or  other  of 
these  means  of  disinfection  may  become  imperative. 

The  heat  required  for  sterilization  in  some  manner  destroys  the 
vital  properties  of  nuclein  of  the  milk  (Starr).  (See  page  96.) 

Pancreatinized  milk  is  used  much  less  for  infants  than  for- 
merly, for  it  has  been  found  that  they  do  not  thrive  if  continuously 
fed  upon  it. 

The  preparation  of  scientifically  "  modified  milk  "  in  milk  labora- 
tories is  fully  described  on  page  103. 

Care  of  the  Milk. —  In  order  to  keep  milk  fresh  and  pure  for  in- 
fant use  in  hot  weather  it  should  be  cooled  at  once  artificially,  and 
if  intended  for  city  consumption,  during  transportation  both  car  and 


836  DIETARIES,   RATIONS 

delivery  wagon  should  be  supplied  with  ice,  so  that  the  milk  tem- 
perature never  rises  above  50°  F.  The  milk  when  received  at  the 
dealer's  should  also  be  kept  in  refrigerators,  for  it  is  exceedingly 
important  that  it  should  not  become  lukewarm  even  temporarily. 
It  is  an  undoubted  advantage  to  have  the  whole  system  of  milk 
supply  under  proper  inspection  and  licensing.  The  cows  when 
stabled  should  be  kept  in  clean,  well-ventilated  quarters,  and  should 
always  have  the  udders  washed  before  milking.  Every  receptacle 
used  for  holding  the  milk  should  be  thoroughly  scoured  with  boiling 
water  each  day,  but  after  first  rinsing  with  cold  water.  If  this  proc- 
ess is  reversed,  particles  of  scalded  milk  may  cling  to  the  pail  or 
can  and  give  rise  to  subsequent  fermentation.  Milk  should  never 
be  allowed  to  stand  about  in  uncovered  vessels,  especially  in  a  bath- 
room, near  an  open  sewer  pipe  or  drain,  or  in  a  damp  cellar.  (See 
Milk  Contamination,  p.  72.) 

When  given  to  the  infant  the  milk,  as  well  as  all  infant  food,  should 
be  moderately  warmed  to  approximate  its  body  temperature  (99°  F.). 

When  the  milk  in  any  form  temporarily  disagrees  it  becomes  neces- 
sary to  substitute  for  it  some  other  form  of  food.  Useful  formula?  for 
this  purpose  are  given  by  Starr  as  follows  : 

Substitutes  for  Milk  in  Infant  Feeding  (Starr) 


Barley-water   ^  ""*.  *  ***  .^1    .'      jeach>  one  and  a  half  ounce' 

Mix. 

Whey  ? 

Barley  water     \   ......................    each>  one  and  a  half  ounce- 

Milk  sugar  ...........................    half  a  drachm. 

Give  one  portion  at  two  months. 

Raw  beef  juice  (one  teaspoonful  every  two  hours)  will  "be  re- 
tained when  everything  else  is  rejected/'  Both  barley  water  and 
lime  water  sometimes  are  added  when  temporary  looseness  of  the 
bowels  occurs. 

In  using  lime  water  (carbonate  of  lime)  as  a  diluent  of  cow's  milk 
it  should  be  remembered  that  in  the  latter  phosphate  of  lime  is  four 
times  greater  in  quantity  than  in  human  milk  (Leeds),  and  it  is 
of  questionable  utility  to  continue  the  practice  beyond  the  require- 
ments of  temporary  indigestion. 

Many  persons  suppose  that  the  milk  from  a  single  cow  is  to  be 
preferred  to  the  mixed  milk  of  several  animals,  and  formerly  some 
dairies  used  to  supply  such  milk  in  separate  bottles.  It  has  been 
proved,  however,  that  there  is  less  variation  in  the  quality  of  mixed 
milk  from  many  cows,  and  the  infant  is  not  so  apt  to  become  dys- 
peptic while  taking  it. 


THE  FEEDING  OF  INFANTS  837 

The  milk  of  fancy  breeds  of  cows,  such  as  that  of  thoroughbred 
Alderneys  or  Durhams,  is  often  too  rich  both  for  infants  and  in- 
valids. 

IV. MIXED   FEEDING 

There  is  no  harm  in  partly  feeding  infants  with  the  bottle  who 
are  at  the  same  time  being  nursed.  If  the  mother  is  suffering  from 
want  of  sleep  she  will  be  of  more  value  to  her  infant  if  allowed  to 
sleep  at  night  while  her  child  is  bottle-fed  once  or  twice.  When  the 
breast  milk  is  insufficient  or  poor  in  quality  the  child  should  be 
fed  by  hand  several  times  a  day  in  addition  to  nursing.  A  hungry, 
ill-nourished  child  cries  continually  in  a  fretful  manner  and  nurses 
irregularly,  either  taking  the  breast  too  long  and  eagerly  or  stopping 
too  soon  if  it  cannot  obtain  the  milk  without  much  effort.  The  sleep 
is  fitful,  the  abdomen  is  .  tender  and  usually  distended  with  gas. 
There  may  be  vomiting,  and  the  stools  are  malodorous  and  contain 
milk  curds.  Sometimes  such  babies  may  be  given  the  bottle  for 
the  greater  part  of  their  food  for  a  few  days,  until  the  mother's  milk 
is  found  to.  agree  with  them  better,  and  thus  the  necessity  for  ab- 
solute weaning  may  be  postponed.  Infants  who  are  brought  up  to 
take  the  bottle  once  or  twice  at  night,  being  nursed  at.  the  breast  in 
the  daytime,  are  usually  more  easily  weaned  when  the  period  for  en- 
tire hand-feeding  arrives. 

When  a  mother  who  has  abundant  milk  supply  is  obliged  to  be 
temporarily  absent  from  her  infant  beyond  the  period  when  a  feeding 
is  due,  she  may  express  beforehand  into  a  clean  glass  a  little  milk 
which  may  be  kept  and  fed  to  the  child  with  a  teaspoon  while  the 
mother  is  away. 

V. — GAVAGE 

When  infants  have  irritable  stomachs,  gastric  catarrh,  or  when 
they  persistently  refuse  food  or  are  too  feeble  and  marasmic  to  take 
sufficient  food,  they  are  fed  by  the  method  of  "gavage,"  which  con- 
sists in  pouring  liquid  nourishment  into  the  stomach  through  a 
glass  funnel  attached  to  a  catheter.  A  soft-rubber  catheter  (No.  7) 
may  be  used.  The  child  is  wrapped  in  a  sheet  to  restrain  the  arms, 
and  then  laid  on  its  back  upon  a  table.  The  catheter  is  passed 
through  the  mouth  for  a  distance  of  about  8  inches,  and  warm 
milk  or  broth  and,  if  necessary,  medicines  may  be  poured  in. 

Weaning 

The  period  for  weaning  varies  considerably,  according  to  the 
health  and  vigor  of  both  mother  and  infant.  Usually  it  should  be 


838  DIETARIES,   RATIONS 

between  the  tenth  and  eighteenth  month,  ordinarily  not  before  the 
tenth  or  twelfth  month  has  been  passed.  Many  infants  are  nursed 
for  fifteen  months,  but  after,  if  not  before  the  eighteenth  month 
the  mother's  milk  deteriorates,  and  the  child's  needs  will  be  better 
met  by  bottle  feeding.  There  can  be  no  fixed  rule  about  this,  how- 
ever, and  much  depends  upon  the  nationality  and  social  position  of 
the  mother.  The  poor,  for  reasons  of  economy,  sometimes  nurse  their 
children  longer  than  is  good  for  them,  and  many  foreign  emigrants  to 
this  country  seem  able  to  nurse  their  infants  longer  than  native 
Americans. 

The  eruption  of  the  eight  incisor  teeth,  which  should  be  com- 
plete by  the  end  of  the  first  year,  is  often  regarded  as  an  indication 
for  weaning.  At  this  time  the  digestive  organs  become  stronger, 
the  saliva  becomes  more  abundant,  and  the  appearance  of  the  an- 
terior molar  teeth  is  a  sign  that  the  stomach  is  gradually  preparing 
for  solid  food. 

Usually,  even  though  the  anterior  molar  teeth  are  cut,  the  child, 
if  weaned,  should  still  be  fed  chiefly  upon  milk  until  the  eighteenth 
month. 

It  is  best  not  to  wean  a  child  during  very  hot  weather,  but  when 
this  is  imperative  milk  alone  should  be  given;  otherwise  a  small 
quantity  of  beef  juice,  egg,  etc.,  may  be  allowed  by  degrees. 

An  infant  may  be  weaned  at  any  time,  and  occasion  may  require 
the  change  suddenly,  but  ordinarily  the  process  should  occupy  at 
least  one  or  two  months.  When  the  child  is  nine  or  ten  months  of 
age  the  bottle  may  be  given  once  a  day  in  place  of  the  breast;  later 
two  or  three  times,  and  so  on,  until  at  the  end  of  a  year  the  weaning 
is  completed.  This,  however,  is  a  very  general  rule,  subject  to  modi- 
fications necessitated  by  the  ill  health  of  mother  or  child,  or  by  hot 
weather,  etc. 

The  circumstances  which  necessitate  earlier  weaning  than  after  the 
twelfth  month  may  be  due  to  the  condition  of  the  infant,  who  may 
have  malformation  of  the  mouth  or  be  congenitally  too  feeble  to  suck, 
or  rendered  so  by  some  disease,  such  as  rickets  or  hereditary  syphilis, 
or  the  condition  of  the  mother  may  be  at  fault,  either  from  constitu- 
tional disease,  such  as  tuberculosis  or  syphilis,  from  local  disease,  ab- 
cess,  or  malformation  of  the  nipples,  from  insufficient  or  poor  milk, 
or  from  the  recurrence  of  menstruation  or  pregnancy. 

If  an  infant  be  nursed  after  the  mother's  milk  has  grown  poor  in 
quality  it  may  acquire  rickets  and  digestive  disorders. 

The  following  directions  for  weaning  an  infant  from  the  bottle 
and  for  feeding  during  the  second  year  are  concisely  given  by  L.  Em- 


THE   FEEDING   OF   INFANTS 


839 


met  Holt  in  his  admirable  brochure  on  The  Care  and  Feeding  of 
Infants.  They  summarize  concisely  a  very  large  experience: 

"  At  ten  months  the  bottle  or  breast  milk  may  be  supplemented 
by  a  little  beef  juice  or  a  portion  of  a  soft-boiled  egg.  If  the  bottle 
is  given,  arrowroot  or  farina  may  be  added  to  one  feeding  each 
day.  .  .  . 

"  During  the  second  year  a  healthy  child  never  requires  more  than 
five,  and  some  do  better  with  four,  meals  during  the  latter  half  of  the 
year.  .  .  . 

"  If  five  meals  are  given,  the  best  hours  are  7  A.  M.,  10  A.  M., 
1  P.  M.,  4  P.  M.,  7  P.  M.,  with  nothing  whatever  during  the  night.  It 
is  better  to  make  the  10  A.  M.  and  4  p.  M.  meals  rather  smaller  than 
the  others." 

Louis  Starr  gives  the  following  mixture  in  commencing  weaning  at 
the  tenth  month: 

Weaning  Mixture  at  Ten  Months   (Starr) 

Cream    f  3  ss. 

Milk   f  I  iv. 

Sugar  of  milk   5  j. 

Water £3  jss.' 

If  disorder  of  digestion  occurs,  return  the  infant  temporarily  to  the 
breast. 

Holt  presents  the  following  table,  based  on  the  measurement  of 
forty  infant  stomachs  and  the  weighing  of  infants  immediately  be- 
fore and  after  nursing.  The  table  gives  the  averages  computed 
from  such  data,  but  the  robust  will  require  a  little  more,  and  the 
feeble  will  take  less  food.  The  measurements  are  in  ounces: 


AGE. 

Quantity  suckled  at  one  feeding. 

Number  of  feed- 
ings. 

Total  daily 
amount. 

2  weeks   

2 

8 

16 

1  month     

3 

8 

24 

2  months  

4 

7 

28 

4  months     

5 

6 

30 

6  months  

5J-6 

6 

33-36 

9  months  

7-7  i 

5 

35-38 

12  months  

8-9 

5 

40-45 

After  the  twelfth  month  three  pints  is  the  limit  of  digestive  ca- 
pacity for  food  for  the  stomach  for  one  day.  If  the  child  seems  to 
need  more  nourishment,  the  strength  of  the  food,  but  not  its  bulk, 
mav  be  increased. 


840  DIETARIES,   RATIONS 

Quantity  of  Food  required  in  the  First  Year  of  Infancy  ( Rotch 


At  each  feeding. 

Number  of  daily 
feedings. 

Total  daily 
amount. 

During  the  1st  week    

in 

At  the  3d  week     

11 

in 

1C          < 

At  the  6th  week    

2 

1  1; 

At  the  3d  month    

3 

9J.      ' 

At  the  4th  month   

4 

7 

00          ( 

At  the  6th  month     

6 

g 

Qfl        ( 

At  the  10th  or  12th  month    

8 

5 

40     * 

Holt's  "  Schedule  for  Feeding  an  Average  Child  in  Health  "  for  the  First  Tear 


AGE. 

Number  of 
meals. 

Interval  by  day 
between  meals. 

Night  feed 
ings,  10  P.M. 
to  6  A.M. 

Quantity  for 
each  meal. 

Quantityfor 
24  hours. 

1  week    

10 
10 
9 

8 
7 
6 
6 
5 
5 

2     hoi 
2 
2 
2i 
3 
3 
3 
3 
3 

irs. 

2 
2 
1 
1 
1 

1       0 

11 

21 
3 

4 
5J 
6 
7J 
8 

z. 

10     0 
15 
20 
24 
28 
33 
36 
37J 
40 

z. 

2  to  3  weeks     .... 
4  weeks    

6        "        

3  months    

5        "         

6        "         

9        "         

12        "         

"  NOTE. —  A  large  child  may  be  given  a  few  ounces  more  in  the  24  hours 
than  the  quantity  above  specified,  a  small  child  a  little  less.  A  large  child 
may  pass  from  one  formula  to  the  next  a  little  more  rapidly  than  at  the  time 
specified,  but  a  small  child,  or  one  with  feeble  digestion,  will  have  to  proceed 
more  slowly.  The  hours  for  feeding  should  in  all  cases  be  observed  with 
regularity." 

The  preceding  tables  differ  only  in  a  few  unimportant  details  — 
less,  in  fact,  than  the  digestive  powers  of  infants  differ  from  each 
other. 

Artificial  Infant  Foods 

Very  young  infants  fed  upon  "  proprietary  "  or  "  prepared  "  baby 
foods  (see  p.  173),  to  the  greater  or  less  exclusion  of  mother's  or 
good  cow's  milk,  soon  become  rhachitic  or  scorbutic.  Wiederhofer  says 
that  "  the  numerous  infant  foods,  although  much  bepuffed,  are  of  no 
value  whatever."  This  is  certainly  true  of  all  non-malted  amyla- 
ceous foods.  The  common  fault  of  nearly  all  such  preparations  is 
that  they  contain  too  much  sugar  or  starch  and  too  little  fat  —  which 
latter  is  very  difficult  to  preserve  without  becoming  rancid.  For  ex- 
ample: Prof.  Leeds  says  that  Mellin's  food  has  only  0.15  part  fat 
in  144.74,  and  Nestle's  food  only  1.91  part  in  139.69,  but  average 
human  milk  has  3.90  per  cent  and  cow's  has  3.66  per  cent. 


THE  FEEDING  OF   INFANTS 


841 


•ri 

•S  ~j                            o  j:  cs  r= 
o^                             co  73       s 

^'l^^-ioS  • 

OJ  ^                                                    ^  ^    S    ^ 

. 

Js 

•°                                                       v 

3^3  "3   >,      J=    >^ 

S 

^J 

•*"  *                                    *S  B  **  "eo 

.53  ^^TS       2  wo 

a 
B 

i 

Water  mus 

L^  "^                                                          "^    S  r2     ^ 

1  °  I             1^1* 

1"    eg                     |_^ 

r^lil 

is"1^!!! 

O    ^  (^    D    4J  ^2  j<^    5^ 

>, 

"^         M         ^                      'P 

'S  B 

X 

wo 

A.      ^       X                   X        Iwo 

* 

IM 

^_      ^'      wo              wo     QQ  «<-. 

03   ti 

03 

£         £         B                    g         ,313   g                    „; 

|1 

O 

11*        1    «Il        « 

HC«                            OQ  Jo                       ^ 

'-'  o 

<N 

Ol         W         «q                      CO                      ^* 

1 

-S  T^  '|  -1 

JO.O.OLJ                     O                                S^ 

^^J,J-t->lJ-*J^          -*J'        .•»• 

"o  si 

£.5 

3 

«<  *  'i  °  H 

^^•^i   l^lifi    1 

0 

us"4  §  § 

^  iO         i£5         IO  2            *^™  *""*            F-H    ^  ^H 

S 

0   0 

i-T 

0  O 

^_^_  ^^s     c^i^i, 

1^ 

en  « 

o  s  rt*  f  *      **"*  «2  •""*  "*"* 

~     ~ 

*tn  « 

*^"»                 *'~>i—  (     73     *  ji*           O             ^ 

•    ^ 

g"c 

4  2 

3 

o       o       «              '         '. 

.S     .3     .5          "       •                        ' 

_u  l- 

—   re 
—    <>« 
SJ5 

X 
X 

li 

O 

X                                             aJ-P  a.  S  .-    • 
X       03      .  •              •         •c«.tJ.>>- 

lo             •       K?  §'  ^  ^  S  fe  *C    • 

5    *°                      02  *°t-  rt  2  °  * 

1  u 

sj 

.^,                X               "->                          —•»             "—-     *    "~>                                                 "-» 

« 

»o 

W<*        »O         WO               WO        WO  *"  WO                             HO 

p 

«*•( 

•              •                                   O3 

..O3                    O3O3.,;O3                                    (B 

jj 

tn         X         03                                                                •'-^ 

s 

f*-         WO             l»O       WO^Q  WO                         k.^. 

«**<*-!                               «4H                                         ,^ 

1 

to 

>H 

:      :      :         :      :      :               i 

B 

•A 

•  i—t            T.              rf.                      T.              !f.      ~     T-                                       00 

-^        on        QD             BD        n  s  CD                       <n 

« 

to 

IO        I^O       MO              MO       MO  5  IM">                           MO 

u 

<M 

1       a    .  «      •*  tJ         'pJ=>T3                    ^ 

. 

-S^^'cc'^cg                   ^ 

HS 

4* 

^j        •*    "  -^         C    K    **  ^3    C   ,»  ""5                      C3 

j^ 

CO          GJ   ^    S         *^    ^    5  *O          ~    tf                      OS 

u 
u 

* 

-c  S  ^  '•I  «  —  t-C'^  5  ^          £-g 

'O+jCM'^C                                     OO—                        °Q 

C 

S       S°E^S-^3C:=O5 

b 

2£2soJ52               S 

O 

56 


842  .DIETARIES,    RATIONS 

Two  extreme  types  are  seen  in  such  infants  —  those  who  are 
emaciated  and  marasmic,  and  those  who  are  stout  and  apparently 
robust,  but  whose  strength  and  power  of  resistance  to  disease  is 
very  deceptive.  As  described  by  Holt:  "When  children  are  fed 
upon  foods  lacking  in  fat,  the  teeth  come  late,  the  bones  are  soft,  the 
muscles  flabby,"  whereas  "  children  fed  upon  foods  containing  too 
much  sugar  are  frequently  very  fat,  but  their  flesh  is  very  soft,  they 
walk  late,  and  they  perspire  readily  about  the  head  and  neck."  They 
present  a  variety  of  rhachitic  deformities,  and  are  subject  to  catarrhal 
and  other  diseases.  Such  foods  should  never  be  fed  to  young  in- 
fants unless  under  a  physician's  direction. 

Another  objection  to  feeding  infants  with  farinaceous  food,  even 
when  partially  converted  by  diastase  into  dextrin  and  maltose,  is 
that  the  final  products  are  unlike  the  carbohydrate  of  normal  milk 
(lactose),  and  it  is  doubtful  whether  they  are  as  readily  assimilated 
and  as  useful  in  the  obscure  metabolic  processes  of  infant  growth. 

Predigested  proteid  foods,  such  as  various  forms  of  meat  extracts, 
albumoses,  etc.,  are  sometimes  used  to  re-enforce  the  milk  of  very 
young  infants.  This  is  a  mistake,  for  the  cow's  milk  is  already  too 
rich  in  proteids.  If  temporary  indigestion  requires  their  use,  they 
should  be  substituted  for  milk,  not  given  with  the  idea  of  re-enforcing 
it. 

Infant  Stools. —  The  stools  of  the  infant  should  be  observed  from 
time  to  time  in  order  to  ascertain  whether  the  milk  is  being  prop- 
erly digested. 

The  stools  of  an  infant  fed  exclusively  on  milk  should  number 
two  (or  only  one)  a  day,  and  be  of  uniform  soft  consistence,  smooth, 
of  inoffensive  odor,  and  of  a  gamboge-yellow  color.  If  meat  juice 
or  meat  broth  of  any  kind  is  given,  the  stools  become  darker.  If 
too  much  is  given  they  become  acid,  malodorous,  very  dark  brown, 
and  diarrhceal. 

\Yhen  firm,  tough  curds  of  paracasein  are  voided,  the  milk  has  been 
exposed  to  too  great  acidity,  either  of  hydrochloric  acid  in  the  stom- 
ach, or  of  lactic  acid  in  gastric  juice,  or  else  the  milk  has  soured 
before  feeding.  To  correct  this  error  the  milk  should  (1)  be  fresh 
and  kept  cool  after  pasteurization;  (2)  lime  water  or  sodium  bicar- 
bonate may  be  added  to  the  milk;  (3)  gruels  may  be  added  to 
mechanically  prevent  the  formation  of  large  curds;  (4)  the  milk  may 
be  peptonized;  (5)  the  quantity  of  milk  may  be  reduced  by  dilution, 
or  ((5)  the  proportion  of  its  components  may  be  altered. 

When  farinaceous  or  any  amylaceous  food  is  being  given,  it  is  well 
to  tost  the  stools  with  a  few  drops  of  tincture  of  iodine  which  ini- 


THE  FEEDING  OF  INFANTS  843 

parts  a  purple  color  to  any  particles  of  undigested  starch  which 
they  may  contain. 

Nursing  Bottles. —  Ever  since  the  influence  of  bacteria  upon  the 
fermentation  of  milk  has  been  established  the  need  for  observing 
carefully  the  most  minute  details  for  cleansing  all  the  infant's  feeding 
utensils  has  been  apparent. 

The  necessity  for  use  of  the  bottle  for  feeding  is  always  to  be  re- 
gretted on  account  of  the  difficulty  of  keeping  the  milk  from  bacterial 
infection.  Adams  says :  "  One  of  the  greatest  nuisances  in  in- 
fantile life  is  the  popular  feeding  bottle.  It  probably  causes  more 
intestinal  diseases  in  the  infant  under  two  years  of  age  than  any 
other  article." 

The  use  of  nursing  bottles  with  long  rubber  tubing  is  to  be 
unhesitatingly  condemned,  although  it  saves  trouble  in  holding  the 
bottle.  It  is  impossible  to  keep  the  tubing  sterile.  The  bottle  should 
be  of  pure  glass,  white,  of  half-pint  capacity,  with  a  wide  mouth 
and  a  sloping  neck,  and  never  with  a  shoulder,  which  prevents  clean- 
ing every  part  of  the  interior  with  a  sterilized  cotton  swab.  A 
measure  of  ounces  should  be  blown  in  the  side,  and  it  should  be 
fitted  with  a  short  black  rubber  nipple,  which  may  be  removed  and 
turned  inside  out  for  thorough  cleansing.  This  short  nipple  has  the 
further  advantage  that  the  child  is  less  likely  to  be  left  by  the  nurse 
alone  with  the  bottle.  The  latter  is  a  slovenly  way  to  feed  an  infant, 
and  should  be  discountenanced,  for  the  child  gets  its  milk  with 
periods  of  delay  and  irregularity.  The  bottle  may  slip  out  of  reach, 
or  after  it  is  empty  the  child  keeps  on  sucking  or  draws  in  air,  and 
obtains  the  milk  at  uneven  temperatures,  or  sometimes  the  child 
goes  to  sleep  with  the  nipple  in  its  mouth,  and,  awaking,  it  finishes 
the  bottle.  "  The  sucking  power  of  the  child  is  to  a  great  extent 
produced  by  the  muscles  at  the  posterior  portion  of  the  mouth;  if 
this  action  is  carried  on  to  too  great  an  extent  it  has  a  tendency  to 
contract  the  width  of  the  mouth  and  cause  protrusion  of  the  teeth  " 
(Cryer).  For  these  reasons  the  nurse  should  always  continue  holding 
the  bottle  in  a  comfortable  position  for  the  child  until  it  has  taken 
its  portion.  This  usually  requires  a  few  minutes  less  time  than  is 
occupied  in  nursing  at  the  breast.  The  usual  time  is  not  above  ten 
minutes  (Dencke).  Any  residue  in  the  bottle  should  at  once  be 
thrown  away,  and  not  warmed  over  for  a  second  feeding,  for  it  is  liable 
to  germ  contamination. 

For  washing  the  milk  bottles  a  solution  of  sodium  bicarbonate  or 
salicylate,  a  teaspoonful  to  the  pint,  should  be  used  first,  after  which 
they  are  thoroughly  scalded  in  boiling  water.  If  fitted  with  a  plug  of 


844  DIETARIES,   RATIONS 

sterilized  baked  absorbent  cotton  they  will  remain  sterile  until  ready 
for  use. 

When  from  six  to  eight  teeth  have  appeared  the  bottle  usually 
may  be  discarded. 

Care  of  the  Infant's  Mouth. —  Cryer  says  that  mothers  or  nurses 
in  caring  for  the  infant  "will  give  attention  to  dirty  hands  or  face 
and  bathe  the  body  daily,  but  how  few  keep  the  mouth  as  clean !  The 
teeth  should  be  brushed  gently  and  thoroughly  with  a  small  soft 
tooth  brush  as  soon  as  .they  make  their  appearance.  .  .  .  Fer- 
mentation of  residual  portions  of  milk  remaining  in  the  mouth  of 
the  infant  after  feeding  is  a  prolific  source  of  gastric  curd,  intesti- 
nal irritation,  giving  rise  to  colic  and  diarrhoea.  The  mouth  of  the 
child  should  therefore  be  kept  carefully  cleansed,  and  before  each 
feeding  be  washed  out  with  a  solution  of  boric  acid  in  distilled  water 
applied  on  a  soft  Linen  rag." 

Weighing  of  Infants. —  The  systematic  weighing  of  infants  at 
least  once  a  week  is  a  very  useful  indication  of  the  progress  in 
nutrition  and  growth  which  they  are  making,  and  it  should  not  be 
neglected. 

Budin  reported  some  interesting  experiments  with  three  classes 
of  infants  —  namely,  (1)  suckled,  (2)  partly  suckled,  partly  artifi- 
cially fed,  (3)  artificially  fed.  During  the  first  fortnight  of  life  he 
found  that  the  gain  in  weight  was  considerably  more  rapid  with 
suckled  infants,  but  during  the  first  year  of  life  the  infant  will  gain 
as  much  weight  if  fed  upon  cow's  milk  as  if  suckled.  Upon  the 
average  the  infant's  weight  should  be  doubled  in  the  first  five  months 
of  life  and  trebled  in  the  first  year.  The  nursing  infant  during  the 
first  three  weeks  of  life  consumes  daily  one-fifth  of  its  own  body 
weight  of  milk. 

Premature  Infants. —  The  feeding  of  premature  infants  demands 
unusual  care.  Their  bodies  are  small;  their  vitality  is  low;  their 
digestion  is  feeble,  and  their  rate  of  heat  loss  is  rapid.  They  are 
sometimes  advantageously  reared  in  incubators.  They  are  often 
too  weak  to  suckle  or  even  to  take  the  bottle  unless  they  are  very 
carefully  hand-fed  so  as  to  obtain  the  milk  without  effort.  It  may 
be  best  to  feed  them  by  gavage.  This  method  takes  less  time  than 
any  other. 

A  very  small,  feeble,  puny  infant  at  nine  months  of  age  may 
not  take  as  much  as  ten  ounces  of  milk  a  day,  and  yet  keep  alive. 
Such  a  baby  should  be  fed  at  shorter  intervals  than  the  rule  allows  for 
well-developed  infants  at  the  same  age,  and  a  two-hour  interval  will 
often  be  best.  Newborn  premature  infants  at  first  may  require  feed- 


FOOD   FOR   YOUNG   CHILDREN  845 

ing  every  hour,  not  above  a  drachm  or  two  of  milk  being  given  at 
a  time. 

FOOD  FOR  YOUNG  CHILDREN 

The  infant,  although  weaned,  should  receive  all  its  food  from 
the  milk  bottle  until  at  least  the  twelfth  month,  and  then  very  gradu- 
ally a  few  other  articles  than  milk  or  beef  juice  may  be  added. 

Children  often  do  well,  however,  upon  a  milk  diet  up  to  the  end 
of  the  second  year. 

"  Towards  the  end  of  the  second  year  all  the  milk  teeth  have 
cut  through,  and  the  digestive  functions  have  greatly  increased  in 
power.  The  lower  maxilla  becomes  stronger,  the  muscles  of  masti- 
cation more  powerful,  the  cavity  of  the  mouth  larger,  the  lips  more 
fleshy,  the  oesophagus  wider;  the  salivary  glands  are  better  devel- 
oped, and  secrete  a  larger  quantity  of  saliva;  the  shape  of  the  stom- 
ach changes,  and  its  walls  grow  thicker,  the  intestinal  canal  longer 
and  more  capacious;  in  short,  all  the  digestive  organs  are  more 
adapted  to  an  animal  diet.  At  this  period  milk  alone  could  not 
satisfy  the  child.  It  may  be  dispensed  morning  and  evening,  but 
during  the  day  more  substantial  food  is  of  absolute  necessity " 
(Ammon). 

Should  illness  of  any  kind  develop  after  a  child  has  been  put  upon 
solid  diet,  it  should  at  once  be  given  only  liquid  food  again,  such  as 
milk  or  meat  broths. 

It  sometimes  happens  that  a  growing  child  acquires  a  distaste 
for  plain  water  and  plain  milk,  and  needs  encouragement  to  take 
fluid  enough  for  physiological  requirements  or  the  elimination  of 
waste.  In  such  cases  the  following  named  articles  afford  consider- 
able variety  for  selection,  and  not  only  supply  necessary  fluid,  but 
small  quantities  of  nutriment  as  well:  toast  water,  thin  farinaceous 
gruels,  such  as  arrowroot  gruel,  etc.;  egg  albumen  water  flavored 
with  cinnamon  or  vanilla ;  "  cambric  tea  "  (i.  e.,  a  cup  of  hot  water 
with  sugar,  a  little  milk,  and  a  mere  trace  of  tea  to  impart  flavor)  ; 
whey,  buttermilk,  koumiss,  and  matzol;  malted  milk;  broths  of  beef, 
mutton,  or  chicken ;  various  meat  extracts  in  hot  water ;  orangeade  or 
pineapple  or  unf ermented  grape  juice ;  somatose  in  peppermint  tea. 

Young  children  of  four  or  five  years  of  age  or  more,  commonly 
crave  sugar,  but  do  not  care  for  fatty  foods.  They  also  like  vegetable 
acids,  and  are  therefore  fond  of  fruits.  These  acids  are  wholesome, 
and  the  fruit  is  laxative  and  healthful  when  ripe. 

It  may  seem  superfluous  to  separately  name  the  chief  prohibited 
substances  which  must  be  kept  from  young  children,  but  experience 


846  DIETARIES,   RATIONS 

proves  the  contrary,  and  when  common  sense  is  lacking  in  those 
who  are  entrusted  with  their  care,  a  written  list  of  these  foods  should 
be  given  them.  If  the  child's  food  is  too  coarse,  too  much  energy  is 
diverted  in  the  attempt  to  digest  it,  and  this  is  at  the  expense  of 
normal  growth  and  development.  Young  children  should  be  kept 
out  of  the  pantry  and  kitchen,  where  their  attention  is  attracted  by 
forms  of  food  which  they  ought  not  to  have  and  with  which  they 
are  liable  to  gorge  themselves. 

Foods  Forbidden  to  all  Very  Young  Children 

The  following  named  substances  are  particularly  indigestible  for 
children,  and  should  not  be  allowed  them  under  four  years  of  age, 
and  some  of  them  should  not  be  given  at  any  period  of  childhood: 
Fried  food  of  all  kinds,  game,  salt  food,  the  flesh  of  swine  in  all 
forms,  pickles,  salads,  condiments,  except  salt,  "  stews,"  the  "  dress- 
ing" of  fowl,  sauces,  visceral  foods  (such  as  liver,  kidneys,  tripe, 
etc.),  all  raw  vegetables,  potatoes  (except  baked),  tomatoes  in  any 
form;  the  coarser  vegetables,  such  as  beets,  turnips,  cabbage,  etc.; 
fancy  bread,  cake,  and  pastry ;  griddle  cakes,  canned  food  of  all  kinds ; 
fancy  confectionery,  sweets,  and  preserves;  cheese,  rich  soups,  jellies, 
dried  or  unripe  and  overripe  fruits  (bananas,  so  often  given  to  young 
children,  are  not  good  for  them),  nuts,  fruits  with  large  seeds,  such 
as  grapes,  the  skin  of  all  poultry,  fruits,  and  vegetables,  such  as  that 
of  potatoes. 

All  food  should  be  plainly  and  thoroughly  cooked.  No  greasy 
or  highly  seasoned  dishes  are  permissible,  and  as  a  rule  twice-cooked 
meats  are  indigestible. 

Tea,  coffee,  and  alcohol  in  every  form  must  be  withheld.  The 
two  former  beverages  interfere  with  digestion  and  make  the  child 
nervous,  and  the  latter  lays  the  foundation  for  a  permanent  alcohol 
habit.  Soda  water  with  sirups  should  not  be  given.  Too  much 
water  should  not  be  allowed  with  meals,  and  what  is  given  should 
not  be  ice  cold. 

Children,  as  they  grow  up,  should  continue  to  observe  regularity 
in  the  hours  for  taking  meals,  and  the  habit  of  perpetually  nibbling 
at  cake,  crackers,  and  confectionery  between  meals  should  not  be 
tolerated.  It  is  best  for  young  children  not  to  be  put  to  sleep  im- 
mediately after  their  most  substantial  meal  of  the  day.  As  they  re- 
quire a  nap  in  the  early  afternoon,  many  advise  giving  this  meal  at 
4  P.  M. 

The  following  is  a  useful  summary  (taken  in  part  from  L.  Emmet 
Holt)  of 


FOOD   FOR  YOUNG   CHILDREN  847 

General  Rules  for  Feeding  Young  Children 

1.  Allow  ample  time  for  meals. 

2.  See  that  the  food  is  thoroughly  masticated. 

3.  Do  not  allow  nibbling  between  meals. 

4.  Do  not  tempt  the  child  with  the  sight  of  rich  and  indigestible 
food. 

5.  Do  not  force  the  child  to  eat  against  its  will,  but  examine  the 
mouth,  which  may  be  sore  from  erupting  teeth  or  stomatitis;  and  ex- 
amine the  food,  which  may  not  be  properly  cooked  or  flavored.     If 
good  food  is  refused  from  peevishness  merely,  remove  it  and  do  not 
offer  it  again  before  the  next  meal  time. 

6.  In  acute  illness  reduce  and  dilute  the  food  at  once. 

7.  In  very  hot  weather  give  about  one-fourth  or  one-third  less 
food,  and  offer  more  water. 

8.  Children  who  persist  in  eating  too  rapidly  should  have  small 
quantities  of  food  put  on  their  plates  at  a  time,  and  should  be  given 
small-sized  forks  and  spoons    (coffee  spoons)   instead  of  the  larger 
adults'  size. 

The  young  infant  depends  exclusively  upon  animal  food,  and  de- 
rives the  necessary  carbon  largely  from  the  sugar  of  milk.  The 
older  child  lives  in  part  only  upon  animal  food,  and  begins  to  derive 
additional  carbon  from  bread  and  other  cereal  foods. 

Quantity  of  Food  Required. —  Experiments  have  been  made  by 
Ueffelmann,  Hasse,  and  others,  to  determine  the  necessary  percent- 
age of  albuminoid  food  required  per  diem  per  kilogram  of  body 
weight,  by  growing  children,  with  the  following  result : 


Albumin. 

Average  weight  of  child. 

At  •' 

4      grams. 

12.5  kilograms. 

At  3 

3.5 

15             " 

At  8 

2.5       " 

24 

Thus  it  is  seen  the  percentage  of  albuminoid  food  required  di- 
minishes as  the  child  gains  in  weight,  and  more  carbohydrate  food 
is  used  to  replace  it. 

The  daily  average  quantity  of  food  required  by  each  child  in  an 
aggregate  of  twenty-eight  healthy  children  between  the  ages  of  two 
and  three  years  is  reported  by  Louis  Starr  as  follows:  Bread,  7.5 
ounces;  butter,  0.98  ounce;  meat  (beef),  4.6  ounces;  potatoes,  3.9 
ounces;  milk,  32.6  fluid  ounces.  The  daily  average  for  each  child 


848  DIETARIES,   RATIONS 

in  an  aggregate  of  twelve  children  between  the  ages  of  three  and 
six  years  was:  Milk,  48.6  fluid  ounces;  beef,  12.1  ounces;  rice,  13 
ounces;  bread,  10.3  ounces;  butter,  1.08  ounce.  The  daily  average 
for  each  child  in  an  aggregate  of  twenty-four  children  between  the 
ages  of  four  and  ten  years  was:  Roast  beef,  12.46  ounces;  bread, 
10.23  ounces;  potatoes,  10.03  ounces;  butter,  0.99  ounce;  milk,  38.5 
fluid  ounces. 

Dietaries  for  Young  Children 

The  following  diets  are  recommended  by  Louis  Starr  as  types  for 
use  from  the  period  of  weaning  up  to  three  and  a  half  years  or 
more: 

Diet  from  the  Twelfth  to  the  Eighteenth  Month  (Starr) 

7  A.  M.,  stale  bread  soaked  in  a  breakfast  cup  of  new  milk. 

10  A.  M.,  milk,  six  ounces,  and  soda  biscuit,  or  a  thin  slice  of 
buttered  bread. 

2  P.  M.,  beef  tea,  six  ounces,  bread,  and  a  tablespoonful  of  rice 
and  milk  pudding. 

6  P.  M.,  same  as  first  meal. 

10  P.  M.,  a  tablespoonful  of  Mellin's  food  in  eight  ounces  of 
milk. 

In  alternation  a  lightly  boiled  egg  with  bread  crumbs  and  six 
ounces  of  milk  may  be  given  at  7  A.  M,,  and  at  2  p.  M.  a  mashed 
baked  potato  moistened  with  four  tablespoonfuls  of  beef  tea,  two 
tablespoonfuls  of  junket. 

Following  is  the  sample  diet  given  by  L.  Emmet  Holt  for  a  child 
eighteen  months  old: 

First  Meal. —  A  tablespoonful  of  some  cereal  with  salt  and  one 
tablespoonful  of  cream,  one-half  pint  of  milk. 

Second  Meal. —  One-half  pint  of  milk. 

Third  Meal. —  One  tablespoonful  of  scraped  meat,  two  small  pieces 
of  dried  bread,  half  a  pint  of  milk. 

Fourth  Meal.—  Milk. 

Fifth  Meal. —  Milk  with  farina  or  arrowroot. 

Instead  of  a  portion  of  milk  scraped  meat  (p.  132),  beef  juice 
(p.  135)  or  a  soft  cooked  egg  may  be  substituted  occasionally.  Of  the 
beef  juice  from  one  to  three  tablespoonfuls  may  be  given  at  a  time. 

"  The  quantity  of  milk  allowed  at  a  single  feeding  for  a  child 
during  the  second  year  should  be  from  eight  to  ten  ounces  during 
the  first  half  and  from  ten  to  twelve  ounces  during  the  latter 
half  of  the  vear." 


FOOD  FOR  YOUXG  CHILDREN  849 

Diet  from  the  Eighteenth  to  the  Thirtieth  Month  (Starr) 

7  A.  M.,  new  inilk,  eight  ounces;  the  yolk  of  an  egg  lightly 
boiled;  two  thin  slices  of  bread  and  butter,  or  else  milk,  and  two 
tablespoonfuls  of  well-cooked  oatmeal  or  wheaten  grits,  with  sugar 
and  cream. 

11  A.  M.,  milk,  six  ounces,  with  a  soda  biscuit  or  bread  and  butter. 

2  P.  M.,  one  tablespoonful  of  rare  mutton  pounded  to  a  paste, 
bread  and  butter,  or  mashed  potatoes  moistened  with  good  dish 
gravy,  a  saucer  of  junket;  or  else  a  breakfastcupful  of  beef  tea  or 
mutton  or  chicken  broth,  a  thin  slice  of  stale  bread,  a  saucer  of  rice 
and  milk  pudding. 

6.30  p.  M.,  a  breakfastcupful  of  milk  with  bread  and  butter,  or 
soft  milk  toast. 

Diet  from  Two  and  a  Half  to  Three  and  a  Half  Years  of  Age  (i.  e., 
for  Children  who  have  cut  their  Milk  Teeth)    (Starr) 

7  A.  M.,  one  or  two  tumblers  of  milk,  a  saucer  of  thoroughly 
cooked  oatmeal  or  wheaten  grits,  a  slice  of  bread  and  butter. 

11  A.  H.  (if  hungry),  a  tumbler  of  milk  or  a  teacupful  of  beef  tea 
with  a  biscuit. 

2  p.  M.,  a  slice  of  underdone  roast  beef  or  mutton,  or  a  bit  of 
roast  chicken  or  turkey,  minced  as  fine  as  possible,  a  mashed  baked 
potato  moistened  with  dish  gravy,  a  slice  of  bread  and  butter,  a  saucer 
of  junket  or  rice  and  milk  pudding. 

7  P.  M.,  a  tumblerful  of  milk  and  a  slice  or  two  of  soft  milk  toast* 

Diet  from  Three  and  a  Half  Years  up  (Starr) 

Breakfast, —  Every  day:  Milk,  porridge  and  cream,  bread  and 
butter. 

One  dish  only  each  day:  Fresh  fish,  eggs  lightly  boiled,  eggs 
poached,  eggs  scrambled,  or  as  a  plain  omelet,  chicken  hash,  stewed 
kidney,  stewed  liver. 

Sound  fruits  may  be  allowed  before  and  after  the  meal,  according 
to  taste,  as  oranges  without  pulp,  grapes  (seeds  not  to  be  swal- 
lowed), peaches,  thoroughly  ripe  pears,  and  cantaloupes. 

Dinner. —  Every  day:  Clear  soup,  meat  roasted  or  broiled  and 
cut  into  small  pieces,  bread  and  butter. 

TVo  dishes  each  day:  Potatoes  baked,  potatoes  mashed,  spinach, 
stewed  celery,  cauliflower,  hominy,  macaroni  (plain),  peas,  string 
beans  (young),  green  corn  (grated). 

Junket,  rice-and-milk  or  other  light  pudding,  and  occasionally  ice 
cream,  may  be  allowed  for  dessert. 


850  DIETARIES,   RATIONS 

Supper, —  Every  day:  Milk,  milk  toast  or  bread  and  butter, 
stewed  fruit. 

From  the  third  to  the  fifth  year  the  child  has  twenty  teeth,  and 
often  three  meals  a  day  suffice,  although  from  the  third  to  the  fourth 
year  four  may  be  given.  After  three  years  of  age  it  is  not  possible 
to  lay  down  definite  rules  for  the  exact  quantity  of  food  allowed,  for 
much  depends  upon  the  child's  size,  rate  of  growth  and  other  con- 
ditions. In  health,  the  appetite  may  be  taken  as  a  fair  guide,  and  the 
child  will  not  eat  too  much  if  taught  to  eat  very  slowly  and  thor- 
oughly chew  each  mouthful. 

When  the  second  set  of  teeth  begin  to  replace  the  deciduous  or 
milk  teeth,  which  gradually  decay,  digestion  is  sometimes  interfered 
with  temporarily  from  lack  of  ability  to  masticate  thoroughly,  and 
food  should  be  subdivided  before  it  is  offered  to  the  child. 

The  following  rules  for  meats  and  vegetables  for  young  children 
are  given  by  L.  Emmet  Holt : 

"  Meats. —  After  eighteen  months,  if  most  of  the  teeth  are  present, 
once  daily,  finely  bruised  or  scraped  rare  roast  beef,  roast  lamb, 
broiled  mutton  chop  or  beefsteak,  white  meat  of  chicken  or  turkey, 
fresh  fish  boiled  or  broiled  —  bones  the  only  objection. 

"  Vegetables.- —  Potatoes  (not  till  after  second  year)  roasted,  peas, 
asparagus  tops,  spinach,  string  beans,  boiled  onions,  stewed  celery; 
all  should  be  very  well  cooked,  in  season,  and  fresh." 

Fruits  are  very  wholesome  food  for  young  children  from  three 
or  four  years  onward,  provided  they  are  properly  selected  and  not 
allowed  in  excess,  which  is  almost  the  only  source  of  trouble  from 
them.  They  serve  to  maintain  the  blood  in  good  condition,  favor  di- 
gestion, and  prevent  constipation.  After  the  fifteenth  month  two  to 
six  teaspoonfuls  of  orange  juice  may  be  given,  and  a  little  later  the 
soft  pulp  of  two  or  three  stewed  prunes,  or  a  half-baked  or  stewed 
apple. 

A  child  three  or  four  years  of  age  may  have  a  piece  of  ripe  pear, 
peach,  or  plum,  or  strawberries  in  season.  Cherries  and  bananas 
should  be  forbidden.  Grape  juice  is  allowed  without  the  skin  or 
seeds.  During  very  hot  weather  great  caution  should  be  observed  in 
giving  fruit  of  any  kind  to  infants. 

Bread,  rice,  oatmeal,  and  other  cereal  foods  should  always  enter 
largely  into  the  dietary  of  healthy  children  after  they  are  able  to 
digest  them.  Their  fats  should  be  derived  chiefly  from  butter  and 
cream. 

Thomas  S.  Southworth  gives  the  following  table  of  hours  for 
feeding  during  the  second  year: 


FOOD   FOR   YOUNG   CHILDREN  851 

7.30  A.  M.,  Breakfast,  including  bottle  of  milk    (diluted  if  necessary). 
11  A.  M.,  Bottle  of  milk,  with  crust  of  zwiebach. 

2  P.  M.,  Dinner,  with  rather  less  milk  as  the  other  food  is  increased. 

U  P.  M.,  Supper,  including  bottle  of  milk. 
10  P.  M.,  Bottle  of  milk. 

During  the  second  half  of  the  year  milk  may  be  taken  from  a  cup 
instead  of  the  bottle. 

Children  between  three  and  four  years  of  age  should  be  fed 
when  in  health  four  times  a  day  —  at  7  A.  M.,  10.30  A.  M.,  1.30  p.  M., 
and  6  p.  M.  The  following  is 

Holt's  " Sample  Diet  for  a  Child  Four  Years  Old" 

First  Meal. —  Half  an  orange,  one  and  a  half  tablespoonfuls  of 
oatmeal  or  hominy,  well  salted,  with  two  tablespoonfuls  of  cream, 
but  no  sugar,  and  one  glass  of  milk. 

Second  Meal. —  A  glass  of  milk  or  cup  of  broth  and  one  slice  of 
stale  bread. 

Third  Meal. —  Meat  —  either  steak,  chop,  or  chicken  —  one  green 
vegetable  (e.  g.,  spinach),  one  starchy  vegetable  (e.  g.,  potato),  water 
to  drink,  stewed  prunes  for  dessert. 

Fourth  Meal. —  Bread  and  milk  or  milk  and  toast. 

Desserts  for  Children 

"  After  two  and  a  half  years  —  plain  custard,  ice  cream  (not 
oftener  than  once  a  week),  rice  pudding  (no  raisins),  baked  apple, 
stewed  prunes"  (Holt). 

The  following  rules  for  feeding  young  children  are  given  by 
Adams: 

When  the  child  has  its  first  sixteen  teeth  it  is  to  be  given  more 
varied  food  than  before,  such  as  stale  bread  and  butter,  crackers, 
mashed  potato  and  gravy,  scraped  beef  sandwiches  with  salt  or 
sugar,  a  piece  of  rare  beef,  or  a  chicken  bone  to  suck.  He  gives 
during  the  period  of  sixteen  teeth: 

6  A.  M.,  a  cup  of  milk,  cream  biscuit,  or  slice  of  buttered  bread; 
8  A.  M.,  stale  bread  broken  and  soaked  in  a  tumblerful  of  rich  milk; 
12  M.,  slice  of  buttered  bread,  half  a  pint  of  weak  beef  tea,  or  mutton 
or  chicken  broth;  4  p.  M.,  tumblerful  of  milk  with  cracker  or  a  slice 
of  buttered  bread;  8  P.  M.,  a  tumberful  of  milk  with  bread  or 
crackers. 

At  the  end  of  the  period  of  sixteen  teeth: 

6  A.  M.,  bread  or  crackers  with  half  a  pint  of  milk;  8  A.  M.,  a 
tablespoonful  of  oatmeal,  cracked  wheat,  or  cornmeal  mush  with 
milk  and  a  couple  of  slices  of  buttered  bread;  12  M.,  bread  and 


852  DIETARIES,   RATIONS 

butter,  milk,  and  a  soft-boiled  egg;  4  p.  M.,  a  piece  of  rare  roast 
beef  to  suck,  mashed  boiled  potatoes,  moistened  with  dish  gravy, 
bread  and  milk,  and  a  small  portion  of  rice,  jelly,  or  farina ;  8  p.  M., 
milk  and  bread  or  crackers. 

Adams  usually  prefers,  however,  to  give  milk  and  oatmeal  water 
or  barley  water  through  the  second. summer. 

If  the  child  vomits  sour  food,  a  little  alkali  should  be  added  to 
the  food  (sodium  bicarbonate,  etc.).  Diarrhoea  may  be  excited  by  a 
too  solid  diet. 

He  prescribes  for  a  child  with  all  the  milk  teeth,  and  able  to 
walk,  up  to  the  third  year : 

8  A.  M.,  well-cooked  oatmeal,  wheaten  grits,  or  cornmeal  mush, 
with  a  liberal  supply  of  milk,  cold  bread  and  butter,  a  piece  of  finely 
cut,  tender  beefsteak  or  a  soft-boiled  egg;  12  M.,  bowl  of  chicken  or 
oyster  soup,  or  weak  beef  tea,  milk  with  bread  or  crackers,  and 
butter;  4  p.  M.,  roast  beef,  mutton,  chicken,  or  turkey,  fresh  white 
fish,  mashed  white  potato  moistened  with  gravy,  bread  and  butter, 
and  rice  and  milk ;  8  P.  M.,  milk  with  bread  or  crackers. 

Bread  and  milk  or  butter  may  be  given  between  the  first  and  sec- 
ond meal  or  before  the  first,  also  ripe  fruit  later. 

For  a  child  from  the  third  to  the  fifth  year  Adams  allows : 

Breakfast. —  Cornmeal  mush,  oatmeal,  wheaten  grits,  hominy, 
plenty  of  cream;  potatoes,  baked  or  stewed;  eggs,  poached,  soft- 
boiled,  omelet;  fish,  fresh  broiled;  meats:  beef  hash,  broiled  steak, 
lamb  chops,  chicken  fricassee;  tomatoes,  sliced;  bread  (cold);  light 
Graham,  entire  wheat,  corn  muffins  (plain),  and  occasionally  Gra- 
ham, corn,  and  rice  cakes ;  fresh,  ripe  fruit. 

Luncheon. —  Soups :  oyster,  clam,  bean,  chicken,  consomme;  vege- 
tables: potatoes,  baked  or  stewed,  sliced  tomatoes;  beefsteak,  lamb 
chop,  cold  roast  lamb;  cold  rolls,  soda  crackers;  fruits  in  season; 
rice  and  milk. 

Dinner. —  Soups:  consomme,  oyster,  cream  of  barley,  potato;  fish: 
baked,  broiled,  or  boiled;  roast  beef,  chicken,  lamb;  stewed  potatoes, 
rice,  cauliflower,  macaroni,  peas,  tomatoes,  beans;  bread,  well-cooked 
wheat.  Desert:  rice  and  milk,  light  pudding,  ice  cream,  fruits,  and 
berries. 

According  to  Minck  and  Ewald,  children  from  two  to  six  years 
of  age  should  be  given  per  kilogram  of  body  weight  per  diem,  proteid 
3.7  grams,  fat  3  grams,  hydrocarbons  10  grams,  which  furnish  col- 
lectively To  calories. 

E.  Mam-el  ( Trait  e  d'  Alimentation  et  de  la  Nutrition)  declares 
that  up  to  the  end  of  the  fifth  year  children  should  have  no  butcher's 


FOOD   FOR  YOUNG   CHILDREN 


853 


meat,  but  they  may  have  chicken  and  fish  not  rich  in  fat  (p.  148). 
They  should  be  given  only  well-cooked  foods,  and  should  subsist  for 
the  greater  part  upon  milk,  bread,  butter,  sugar,  soups,  and  eggs. 
During  the  sixth  and  seventh  years  he  allows  fresh  vegetables,  well 
cooked,  and  fruits  in  the  form  of  marmalade  (jam)  or  compote.  His 
diet  limitations  are  as  follows  per  diem: 


Proteid. 

Fat 

Carbohy- 
drates. 

Calories. 

3d  year    

20.5 

33 

66. 

663.5 

4th    "       

25. 

40 

71 

715 

5th—  7th  year    

32 

40 

94  5 

870 

10th  year    

49 

49 

145 

1,330 

14th     "       

70  5 

61 

269 

1  998  5 

18th     "       

93 

82 

293 

2  415 

Maurel  states  that  in  early  childhood  the  food  should  be  in  fluid 
and  semisolid  form,  and  if  cereals  and  vegetables  be  utilized  without 
removal  of  cellulose  and  fiber,  they  will  furnish  sufficient  proteid 
without  resort  to  meat.  Moreover,  sugar  should  be  added  freely 
to  food  at  the  table.  (This  dietary  represents  an  extreme  French 
point  of  view,  leaning  toward  modified  vegetarianism.) 

Teething  and  Food 

Much  illness  and  digestive  disturbance  in  infancy  and  early  child- 
hood is  popularly  ascribed  to  "  teething,"  and  the  gums  do  occa- 
sionally become  swollen  and  inflamed  during  dentition,  but  the  evils 
of  this  process  are  exaggerated  in  the  lay  mind  and  wrong  feeding 
is  much  more  often  accountable  for  the  disturbance.  In  regard  to 
this  matter  Adams  says,  "  My  experience  has  taught  me  that  when- 
ever the  child  has  become  ill  during  this  physiological  process,  some 
other  cause  than  the  mere  cutting  of  the  teeth  can  be  found  to 
account  for  the  illness." 

Sleep  and  Feeding 

The  relation  of  sleep  to  infant  feeding  is  very  well  summarized 
by  Adams  as  follows :  "  A  young  infant  has  nothing  to  do  but  eat 
and  sleep.  As  soon  as  he  is  fed  he  will  take  a  nap  and  will  prob- 
ably sleep  for  an  hour  and  a  half.  After  the  first  year  the  naps 
become  shorter  and  less  frequent.  During  the  second  year  a  nap 
in  the  morning  after  breakfast,  one  in  the  afternoon  about  one  or  two 
o'clock  for  an  hour  or  an  hour  and  a  half  are  usually  sufficient,  and 
these  naps  should  be  insisted  upon  for  the  rest  of  his  mind  and  body, 


854  DIETARIES,   RATIONS 

and  to  enhance  his  growth  and  health.  As  the  child  attains  the 
third  year,  he  can  usually  drop  the  morning  nap.  The  afternoon 
one  should  be  insisted  upon  very  soon  after  the  child  has  its  noon- 
day meal,  in  winter  as  well  as  in  summer." 

DIET  FOR  SCHOOL  CHILDREN 

Too  much  attention  cannot  be  given  by  teachers  to  the  diet  of 
the  pupils  under  their  care  in  boarding  schools,  and  they  should 
exercise  some  supervision  in  regard  to  the  matter  in  day  schools 
as  well,  for  the  subject  is  often  ill  understood  by  parents. 

The  period  for  training  most  school  children  is  from  the  tenth  to 
the  seventeenth  or  eighteenth  year,  but  with  the  present  system  of 
kindergarten  training  the  attendance  at  school  may  begin  much 
younger.  During  the  entire  time  both  mind  and  body  are  under- 
going development,  which  in  many  instances  is  exceedingly  rapid, 
and  in  the  midst  of  this  period  the  condition  of  puberty  is  attained, 
which  in  itself  requires  additional  care  and  watchfulness,  especially  in 
girls.  (See  p.  855.) 

Throughout  the  whole  school  period  the  growth  of  the  body  is  con- 
tinued until  almost  completed.  The  individual  organs  and  structures 
increase  in  actual  size,  and  there  are  unusual  demands,  therefore,  upon 
the  functions  of  absorption  and  assimilation.  The  food  should  be 
abundant  and  of  the  proper  character  to  furnish  new  tissue  and  to 
yield  energy  in  the  form  of  heat  and  muscular  activity.  The  former 
condition  is  met  by  a  proper  allowance  of  animal  food  in  the  diet,  and 
the  latter  by  sufficient  fats  and  carbohydrates.  The  food  should  also 
contain  salts  of  lime,  to  meet  the  requirements  of  formation  of  the 
bones  and  teeth.  While  the  material  or  structural  development  of 
the  body  progresses,  there  is  also  a  marked  development  in  the  func- 
tions of  the  various  organs ;  the  muscles  are  trained  to  act  with  vigor 
and  with  proper  co-ordination,  and  the  nervous  system  is  constantly 
receiving  and  storing  new  impressions  and  regulating  their  transmis- 
sion and  the  proper  relations  of  inhibitory  and  reflex  actions.  The 
metabolic  processes  of  the  body  are  extremely  active  and  the  digestive 
secretions  are  vigorous.  To  maintain  the  proper  standard,  therefore, 
of  growth  and  development  requires  care  in  the  selection  of  the 
right  quantity  and  quality  of  "  fuel  "  or  food  for  the  body,  and  the 
lack  of  such  care  too  often  lays  the  foundation  of  an  enfeebled  con- 
stitution. 

Many  children  inherit  feeble  constitutions  or  diatheses,  which  must 
be  combated  throughout  the  whole  period  of  childhood.  Such  chil- 
dren are  better  kept  at  home,  where  they  can  be  under  constant 


DIET  FOR  SCHOOL  CHILDREN  855 

observation  and  proper  dietetic  treatment,  or  country  schools  may  be 
found  for  them  where  such  matters  are  made  the  subject  of  special 
consideration. 

Many  cases  of  anaemia  and  chlorosis,  which  are  so  commonly  seen 
in  young  girls  during  or  shortly  after  the  attainment  of  the  condition 
of  puberty,  are  directly  traceable  to  malnutrition  from  faulty  diet. 
Girls  take  less  exercise  than  boys,  as  a  rule,  and  are  more  likely  to 
become  constipated.  This  difficulty  may  be  enhanced  by  a  lack  of 
sufficient  fresh  vegetables  or  fruit  in  their  diet,  and  if  prolonged  it  is 
enough  in  itself  to  cause  anemia.  The  latter  also  may  be  brought 
about  by  insufficient  good  animal  food.  It  should  be  the  imperative 
duty  of  every  head  master  of  a  school  for  children  to  realize  the  re- 
sponsibilities of  rightly  developing  the  physical  constitutions  of  those 
entrusted  to  his  care,  and  to  make  a  thorough  study  of  "the  questions 
of  dietetics  involved.  The  mind  continues  developing  long  after  the 
body,  and  the  period  under  discussion  is  one  in  which  the  constitution 
is  established  for  the  remainder  of  life,  and  when  success  in  digestion 
and  assimilation  is  of  greater  importance  than  success  in  mental 
attainments. 

Variety. —  An  important  consideration  in  school  diet  is  to  prevent 
monotony,  which  becomes  so  common  from  economic  reasons,  or  often 
from  carelessness.  But  a  little  study  and  thought  expended  upon 
this  subject  can  always  result  in  furnishing  variety  in  a  wholesome 
diet  without  material  increase  of  expense. 

The  French  Minister  of  Public  Instruction  appointed  a  Commission 
to  recommend  a  proper  diet  for  school  children.  Eeporting  for  this 
Commission,  Bouchard  declared  that  for  adolescents  the  proportion 
of  proteid  to  carbohydrate  food  should  not  exceed  the  ratio  1:5.  If 
it  becomes  1 : 4  digestive  disorders  may  ensue,  with  fetid  stools,  skin 
eruptions  and  excess  of  urinary  sediment. 

Diet  and  Puberty 

At  the  advent  of  puberty  special  care  should  be  exercised  in  dieting 
children,  for  it  is  believed  that  condiments,  peppers,  spices,  eggs, 
oysters,  and  especially  an  excess  of  animal  proteid  food  is  prone  to 
overstimulate  the  sexual  organs.  Bouchard,  Le  Gendre,  E.  Maurel 
all  emphasize  the  importance  of  reducing  the  meat  diet  to  a  minimum 
at  this  period. 

Maurel,  moreover,  believes  that  vegetable  proteid  does  not  possess 
this  stimulating  effect  in  common  with  meat  proteid,  hence,  he  argues, 
it  may  not  be  due  to  the  proteid,  but  some  other  ingredient  [extrac- 
tives?] taken  with  it  in  meat.  The  quantity  of  food  also  should  not 


856  DIETARIES,   RATIONS 

be  excessive  at  this  period,  or  it  will  tend  to  produce  indigestion  and 
disordered  sleep. 

Hours  for  Meals 

The  hours  for  study  and  for  meals  should  be  so  regulated  that  suffi- 
cient time  be  allowed  before  each  meal  for  children  to  prepare  them- 
selves comfortably  without  going  to  the  table  excited  by  hurry,  and 
they  should  be  required  to  remain  at  the  table  throughout  a  fixed 
time,  never  being  allowed  to  swallow  hastily  their  food  in  order  to 
complete  an  unfinished  task  or  game.  An  interval  of  half  an  hour  or 
more  should  intervene  for  recreation  after  meals,  in  order  that  diges- 
tion may  be  well  under  way  before  any  mental  exertion  is  required. 
Constant  nibbling  at  food  between  meals  should  be  forbidden;  it  de- 
stroys the  appetite,  increases  the  saliva,  and  interferes  with  gastric 
digestion.  The  number  of  meals  for  children  should  be  adapted  to 
the  age  of  the  pupils.  For  young  children  from  ten  to  twelve  or 
thirteen  years  of  age  it  may  be  necessary  to  furnish  food  somewhat 
oftener  than  for  older  ones. 

If  children  live  at  a  distance  from  their  school,  or  if  they  are  weak 
and  easily  fatigued  and  inclined  to  sleep  long  in  the  morning,  their 
hours  for  study  should  be  so  adjusted  that  they  are  never  obliged  to 
hurry  their  eating  in  order  to  be  on  time  for  school  work.  Their 
appetites  are  often  poor  at  this  hour  from  the  effects  of  an  ill-ven- 
tilated sleeping  apartment,  and  if  they  are  subsequently  kept  at  school 
for  five  hours  without  luncheon  they  are  ill  fitted  for  mental  work. 
Or  they  ride  to  school  without  exercise  after  a  hasty  breakfast,  take  a 
hurried  cold  lunch  at  noon,  and  perhaps  a  warmed-over  late  afternoon 
dinner,  and  at  six  or  seven  o'clock  a  fourth  meal,  after  which  they  are 
expected  to  study  and  go  to  bed. 

A  fact  which  is  sometimes  overlooked  in  the  dietetic  treatment  of 
growing  children  is  that  their  digestive  processes  are  so  active  that 
the  stomach  is  emptied  somewhat  sooner  than  in  the  case  of  adults, 
and  their  meals  being  promptly  absorbed,  it  is  natural  for  them  to 
become  hungry  if  the  intervals  between  the  hours  of  eating  are  pro- 
longed. In  some  schools,  children  are  given  their  last  meal  of  the 
day  at  six  o'clock  in  the  evening,  and  they  may  not  breakfast  until 
seven  or  half-past  seven  or  later,  leaving  an  interval  of  over  thirteen 
hours  during  which  they  have  had  no  food  at  all.  The  evening  meal 
is  usually  made  light,  on  the  ground  that  they  can  sleep  better,  and  it 
is,  therefore,  sooner  digested.  Robust  children  may  thrive  on  this 
treatment,  but  those  less  strong  are  injured  by  it.  For  some  school 
children  of  from  ten  to  fourteen  years  of  age  it  is  better  to  serve  the 


DIET  FOR  SCHOOL  CHILDREN  85? 

evening  meal  later,  at,  say,  seven  o'clock,  and  the  breakfast  at  seven, 
and  if  they  awaken  hungry  during  the  night  there  is  no  harm  in  their 
having  a  glass  of  milk  and  a  cracker. 

Delicate  children  whose  appetites  are  poor  and  who  do  not  do 
proper  justice  to  their  regular  meals  should  be  offered  an  extra  portion 
of  hot  broth  or  hot  milk  or  an  occasional  cup  of  chocolate  with  bread 
and  butter  and  rusk  between  meals. 

These  general  rules  are  applicable  to  those  children  who,  during 
one  or  two  years,  seem  to  develop  with  extraordinary  rapidity,  grow- 
ing sometimes  two  inches  or  more  in  six  months  and  attaining  a 
height  quite  disproportionate  to  their  frames.  The  demands  of  this 
rapid  growth  must  be  met  by  proper  nutrition  or  serious  subsequent 
impairment  of  vitality  may  result.  Such  children  should  have  their 
meals  made  tempting  by  good  cooking  and  pleasant  variety  as  well  as 
an  agreeable  appearance  of  the  food.  Meat  which  is  carved  in  un- 
sightly masses  and  vegetables  which  are  sodden  and  tasteless  may  be 
refused,  and  an  ill  attempt  is  made  to  supply  the  deficiency  in  proper 
food  by  eating  indigestible  candy,  nuts,  etc.  Children  often  have  no 
natural  liking  for  meat,  and  prefer  puddings,  pastry,  or  sweets  when 
they  can  obtain  them,  and  it  is  the  more  important  that  meat  should 
be  made  attractive  to  them  at  the  age  when  they  need  it. 

It  is  unnecessary  to  discuss  further,  questions  which  after  all  must 
be  controlled  by  tact  and  circumstances  of  individual  cases,  and  the 
line  should  be  drawn  with  care  between  making  a  child  too  fastidious 
on  the  one  hand  in  regard  to  the  nature  of  its  food,  and  on  the  other 
impairing  its  constitution  by  monotony  of  diet  and  ill-cooked  viands. 
Children  at  school  especially  should  be  required  to  eat  slowly,  for  the 
habit  of  fast  eating  is  contagious,  and  as  it  is  much  easier  to  acquire 
than  to  overcome,  the  foundation  of  dyspepsia  and  lifelong  discomfort 
may  be  laid  in  this  way  in  childhood.  The  food  served  should  be 
given  in  successive  helpings,  rather  than  all  at  once. 

A  Sample  Diet 

If  early  rising  be  insisted  upon,  a  child  should  never  be  set  at  any 
task  before  breakfast,  especially  in  winter,  and  if  not  expedient  to 
serve  a  full  breakfast  at  half-past  six  or  seven  the  child  should  be 
given  a  bowl  of  hot  milk  and  bread,  or  a  cup  of  cocoa  with  a  roll,  or 
other  light  food:  breakfast  may  be  served  later  after  the  first  exer- 
cises of  the  morning,  and  should  be  a  substantial  meal  with  animal 
food  in  the  form  of  either  fish,  or  eggs,  or  cold  meat  of  some  sort,  with 
porridge  of  wheaten  grits,  or  hominy  with  milk  or  cream  and  abun- 
dant sugar,  also  bread  and  butter,  with  sweets  in  the  form  of  jam,  or 


858  DIETARIES,   RATIONS 

marmalade,  or  stewed  fruit.  Dinner,  which  should  be  served  near  the 
middle  of  the  day,  may  comprise  meat,  potatoes,  with  one  or  two  green 
vegetables,  and  some  form  of  sweet  pudding.  The  supper  should  com- 
prise only  easily  digestible  articles  of  food,  and  such  substances  as 
pastry,  cheese,  and  meats,  are  better  omitted.  It  should  consist  of 
either  a  porridge  with  milk  or  cream,  or  a  light  farinaceous  pudding 
of  rice,  tapioca,  sago,  and  the  like,  with  bread  and  butter,  and  a  sim- 
ple form  of  preserve,  or  stewed  apples  or  prunes.  Very  light  plain 
cake,  or  a  good  bowl  of  nutritious  broth  with  bread  or  crackers  may 
be  substituted  for  the  porridge  or  pudding.  It  will  sometimes  be 
found  best  to  serve  this  meal  at  seven  o'clock  or  half  past  seven,  and 
if  hungry  the  child  may  be  given  a  slice  of  bread  and  butter  and  a 
cup  of  weak  tea  or  coffee,  mostly  hot  milk,  at  half  past  five  or  six 
o'clock. 

Sample  diet  from  a  well-known  Boys'  School  in  New  England. 

Breakfast,  7.30  A.  M. —  Oatmeal.  Bread  and  butter.  Stew  or 
hashed  meat,  or  beefsteak  or  chops.  Twice  a  week,  griddle  cakes  with 
sirup. 

Dinner,  1  p.  M. —  Soup.  Fish  once  or  twice  a  week.  Meat,  either 
roast  beef,  beefsteak,  mutton,  or  chicken.  Potatoes  and  green  vege- 
tables in  season.  Pudding,  or  pie,  or  plain  cake,  and  lemonade. 
Fruit. 

Supper,  7  P.  M. —  Cold  meat,  or  hashed  meat,  or  fish  balls.  Pota- 
toes. Bread  and  butter.  Cake.  Preserved  fruits. 

Time  Allowed  for  Meals. —  Breakfast  and  supper,  each  half  an 
hour ;  dinner,  three-quarters  of  an  hour.  Intervals  of  rest  or  recrea- 
tion for  the  younger  boys  (thirteen  to  fourteen  years),  after  break- 
fast, half  an  hour;  before  dinner,  three-quarters  of  an  hour;  after 
dinner,  two  hours  and  a  half;  before  and  after  supper,  fifteen  minutes. 

On  Sundays,  breakfast  an  hour  and  dinner  half  an  hour  later  than 
on  week-days,  and  supper  five  hours  after  dinner. 

Some  of  the  more  important  articles  of  school  diet  require  special 
mention. 

Bread,  as  a  rule,  should  be  made  of  whole  meal,  but  should  not  be 
too  coarse.  The  advantage  of  this  bread  for  children  consists  in  its 
containing  a  larger  proportion  of  salts,  which  they  need,  than  is 
found  in  refined  white  flour,  and  butter  should  be  freely  served  with 
it.  to  supply  the  deficiency  of  fats  which  exist  in  wheat.  Children 
need  fat.  but  they  do  not  digest  meat  fat  well,  as  a  rule,  and  are  very 
apt  to  dislike  it.  They  will  often  take  suet  pudding,  however,  when 
hot  mutton  fat  disagrees. 


DIET  FOR  SCHOOL  CHILDREN  859 

Milk  should  be  supplied  freely  not  only  in  the  form  of  puddings 
and  porridges,  but  as  an  occasional  beverage,  and  children  should 
understand  that  when  hungry  they  may  obtain  a  glass  of  milk,  or  a 
bowl  of  crackers  or  bread  and  milk,  for  the  asking. 

Chambers  says :  "  The  best  luncheon  that  a  growing  young  man 
can  have  is  a  dish  of  roast  potatoes  well  buttered  and  peppered  and 
a  draught  of  milk." 

Fresh  Fish,  eggs,  and  bacon  are  all  wholesome  and  serviceable  foods 
for  children. 

Meat,  as  a  rule,  may  be  given  twice  a  day,  but  not  oftener.  It 
may  sometimes  be  advisable  to  give  it  only  once  a  day  when  fish  or 
eggs  are  supplied;  it  should,  however,  always  be  given  at  least  once 
daily,  and  better  twice  to  rapidly  growing  children.  Large,  strong 
boys  require  much  meat,  and  its  use  should  not  be  stinted.  The 
larger  boys  may  eat  from  seven  to  nine  ounces  of  cooked  meat  in  the 
day,  although  many  children  may  not  require  so  much,  smaller  boys 
doing  well  with  from  five  to  six  ounces. 

During  midwinter,  however,  when  fresh  vegetables  are  almost  un- 
obtainable in  severe  climates,  vigorous  boys  sometimes  have  too  much 
meat  given  them,  and  Yeo  calls  attention  to  the  fact  that  eczema 
may  be  produced  in  them  by  a  too  exclusive  animal  diet. 

Sweets. —  The  greater  number  of  children  have  a  natural  craving 
for  sweets.  The  important  role  of  sugars  in  furnishing  energy  for 
the  body  has  been  discussed  (p.  22},  and  the  energy  developed  in 
active  childhood  necessitates  the  consumption  of  a  larger  proportion 
of  sugar  than  is  required  by  adults.  The  craving  of  children  for 
confections,  candy,  etc.,  furnishes  a  true  indication  of  the  actual 
requirements  of  Mature,  and  a  moderate  amount  of  wholesome  candy, 
like  plain  molasses  candy  or  plain  chocolate  caramels,  not  only  does 
most  children  no  harm,  but  may  serve  them  as  an  excellent  food. 
The  main  difficulty  with  such  forms  of  sugar,  however,  often  is  that 
children  are  not  furnished  with  a  proper  proportion  of  sugar  with 
their  meals,  and  the  meals  themselves  are  not  so  regulated  as  to 
prevent  their  becoming  very  hungry  between  them;  consequently, 
if  they  can  obtain  candy,  which  satisfies  them  for  the  time,  they  eat 
too  much,  with  the  result  of  producing  dyspepsia  and  diminishing 
the  normal  appetite.  If  pains  be  taken  to  give  such  children  a  slice 
of  bread  and  butter  with  a  little  honey  or  jam  between  meals  and  a 
proper  proportion  of  saccharine  food  with  their  meals,  they  are  much 
less  likely  to  obtain  candy  surreptitiously  and  gorge  themselves  with  it. 
Simple  forms  of  well-cooked  pastry  and  of  cakes  with  stoned  raisins 
should  be  furnished  as  dessert  occasionally.  It  is  better  to  give  such 


860  DIETARIES,   RATIONS 

food  from  time  to  time  with  the  meals  under  proper  supervision  than 
to  have  children  indulge  themselves  in  it.  Milk  sugar  is  an  excellent 
children's  food,  as  it  is  good  for  infants. 

Alcohol  in  every  form  should  be  forbidden  to  healthy  children.  If 
given  during  early  youth  it  is  particularly  prone  to  develop  a  taste 
which  may  become  uncontrollable  in  later  years. 

Habit. —  Many  children  acquire  a  habit  of  dislike  or  even  disgust 
for  certain  articles  of  food,  which  becomes  so  fixed  in  later  life  that 
they  find  it  very  inconvenient,  especially  when  placed  in  circum- 
stances, as  in  traveling,  where  one  cannot  always  obtain  the  accus- 
tomed diet.  Giving  in  to  such  habit  is  often  a  serious  obstacle  to 
normal  development.  There  are  children  who  acquire  a  dislike  for 
meat  and  who  persistently  refuse  to  take  it,  until  they  become  anaemic 
and  feeble,  and  there  are  others  who  refuse  fresh  vegetables,  which 
they  need.  It  is  a  great  misfortune  for  a  child  to  be  indulged  in 
such  likes  or  dislikes.  With  a  little  tact  and  persuasion  the  repug- 
nance usually  may  be  overcome  before  the  habit  becomes  rooted,  and 
the  question  is  largely  a  matter  of  proper  education.  How  often  is 
the  physician  baffled  in  the  treatment  of  a  serious  disease  like  typhoid 
fever,  which  requires  the  use  of  a  milk  diet,  by  the  patient's  insisting 
that  he  has  never  been  able  to  drink  milk  since  childhood !  If  there 
be  any  taste  which  is  natural  to  all  men  it  is  that  for  milk,  upon 
which  all  must  live  during  early  infancy ;  and  while  it  is  better  after  a 
certain  period  of  growth  to  restrict  the  quantity  of  milk  in  the  diet, 
there  is  no  reason  at  all  why  children  should  not  retain  a  normal  fond- 
ness for  it.  There  are,  no  doubt,  cases  in  which  it  disagrees  (see  p. 
83),  but  they  are  exceptional  as  compared  with  the  number  of  persons 
who  can  digest  milk,  when  properly  prepared,  with  perfect  ease,  but 
whose  antipathy  for  it  prevents  them  from  taking  it  in  the  emergen- 
cies which  may  befall  them  in  acute  disease. 

Children  who  object  to  vegetables  sometimes  may  learn  to  eat  them 
when  cooked  in  an  unusually  attractive  manner  or  served  in  soup. 

Overeating  should  be  guarded  against,  for  habits  of  gluttony  may 
be  acquired  in  youth,  especially  between  puberty  and  full  develop- 
ment, which  are  never  overcome,  and  which  may  lead  to  visceral  dis- 
tention  and  hypertrophy,  obesity  and  other  troubles,  that  develop  in 
adult  life.  The  habit  of  slow  eating  should  be  insisted  upon. 

Exercise,  etc. —  As  a  general  rule,  active  muscular  exercise  in  chil- 
dren disturbs  their  digestive  processes  far  less  than  mental  effort  when 
taken  immediately  after  meals,  and  every  adult  is  familiar  with  the 
romping  which  children  can  undertake  straightway  after  dinner,  often, 
though  not  always,  with  impunity,  whereas  a  proportionate  amount  of 


HOSPITAL  DIETARIES  861 

exercise  on  the  part  of  an  adult  might  produce  a  severe  dyspeptic 
attack.  It  is  well  to  allow  children  to  play  only  moderately  imme- 
diately after  eating,  and  to  require  no  mental  work  of  them  at  such 
time. 

For  some  reason  both  the  diet  and  exercise  in  girls'  schools  is  often 
less  carefully  regulated  than  in  corresponding  schools  for  boys.  This 
applies  not  only  in  the  United  States,  but  has  been  found  the  com- 
mon experience  in  England  and  France;  it  is  the  more  unfortunate, 
since  girls  from  their  greater  delicacy  of  constitution,  especially  at 
the  period  of  puberty,  require  more  careful  nurture.  Differences  in 
habits  and  exercise  and  outdoor  recreation,  no  doubt  in  part,  are 
responsible  for  the  comparative  lack  of  proper  development  in  some 
girls'  schools,  but  this  should  be  recognized  and  regulated  with  as 
much  care  as  the  diet. 

During  the  establishment  of  puberty  it  is  best  for  children  to  avoid 
stimulating  and  highly  seasoned  food,  and  eating  late  at  night,  which 
is  apt  to  excite  the  sexual  organs  reflexly  and  cause  lascivious  dreams. 
(See  Diet  and  Puberty,  p.  855.) 

HOSPITAL  DIETARIES 

Statistics  of  the  most  economical  quantity  and  quality  of  food  for 
men  in  health,  and  under  different  conditions  of  activity,  have  been 
very  accurately  and  practically  determined,  but  such  data  for  the  sick 
are  in  most  cases  unobtainable,  and  obviously  so,  for  the  condition 
of  individual  cases  and  the  severity  of  diseases  are  constantly  varying 
from  day  to  day,  and  no  definite  rules  for  the  exact  quantity  of  food 
needed  could  be  formulated  which  would  be  of  general  application. 
For  this  reason  in  many  hospitals  no  attempt  is  made  to  classify  the 
diet  beyond  the  very  elementary  subdivisions,  consisting,  first,  of 
milk  diet  —  i.  e.,  milk  alone,  or  of  milk  with  a  little  bread,  and  light 
farinaceous  food ;  secondly,  the  "  full  diet,"  which  is  commonly  known 
either  by  that  name  or  as  "  house  diet "  or  "  ordinary  diet."  Where 
no  further  general  classification  of  the  diet  is  attempted,  it  is  cus- 
tomary to  have  a  supplementary  list  of  foods,  usually  called  "  articles 
of  special  diet,"  from  which  the  visiting  physician  or  surgeon  is  to 
select  appropriate  food  for  individual  cases.  The  expression  "low 
diet,"  indicating  that  for  very  sick  patients,  is  an  unfortunate 
one,  as  it  has  a  depressing  sound.  In  other  institutions,  where  more 
care  is  bestowed  upon  dietetics,  it  is  found  both  convenient  and  prac- 
tical to  subdivide  the  diet  under  several  additional  headings.  This 
arrangement  is  commended,  as  it  not  only  saves  time  and  confusion, 


862  IflETARIES,   RATIONS 

but  is  economical  to  the  institution  in  preventing  waste,  instead  of 
sending  a  large  number  of  "  full  diets  "  from  the  kitchen  to  the  ward, 
where  the  lighter  or  more  easily  digestible  articles  are  selected  for  the 
sicker  patients  by  possibly  inexperienced  nurses,  much  of  the  food 
being  returned  uneaten.  If  the  diet  is  assorted  in  the  kitchen  and 
sent  to  the  ward  in  a  properly  classified  condition  — •  that  is,  so  many 
rations  of  each  specified  class  —  there  is  very  much  less  waste  and 
confusion. 

Under  this  system,  the  subdivisions  which  I  have  introduced  in 
several  metropolitan  hospitals  are  as  follows : 

I.  Milk  diet,  consisting  of  from  two  and  a  half  to  three  quarts  of 
milk  per  diem,  and  nothing  else. 

II.  Convalescent  diet,  or  "  half  diet,"  or  "  light  diet "  as  it  is  vari- 
ously called,  intended  for  patients  convalescing  from  acute  disease,  or 
for  patients  who  are  unable  to  digest  the  full  house  diet.    In  the  aver- 
age medical  ward  the  majority  of  patients  live  usually  upon  this  diet, 
which  is  not  adapted  for  the  special  requirements  of  any  particular 
disease,  but  is  simply  light,  nutritious,  and  easy  of  digestion,  and 
is  therefore  serviceable  in  a  very  large  number  of  cases  which  do  not 
need  more  careful  selection  of  food. 

III.  Non-nitrogenous  diet,  from  which  animal  food,  with  perhaps 
the  exception  of  milk  and  butter,  is  excluded.     It  comprises  bread 
and  other  cereals,  vegetables  and  fruit.     This  diet  is  not  of  very  gen- 
eral use,  but  is  temporarily  serviceable  in  some  forms  of    disease,  such 
as  chronic  Bright's  disease  and  acute  gout. 

IV.  Proteid  diet,  or  animal  food,  which  is  somewhat  more  used 
than  the  preceding  diet,  and  from  which  saccharine  and  almost  all 
forms  of  starchy  food  excepting  a  little  dried  bread,  toast,  or  Graham 
bread  are  excluded.     It  consists  mainly  of  meats,  but  comprises  also 
fish  and  eggs.     This  diet  is  particularly  serviceable  in  cases  of  flatu- 
lent dyspepsia,  chronic  gastric  catarrh,  and  dilatation  of  the  stom- 
ach, in  which  the  starches  and  sugars  invariably  undergo  acid  fer- 
mentation,   with    eructations    and    flatulence.     It    also    serves    for 
diabetics,  with  slight  modification. 

V.  House  or  full  diet  should  be  the  most  economical  diet  for  the 
hospital  upon  which  patients  who  have  nearly  completed  their  con- 
valescence may  be  placed,  as  well  as  those  patients,  including  certain 
medical  cases  and  a  large  number  of  minor  surgical  patients,  whose  di- 
gestive organs  are  in  normal  condition.     It  comprises  many  coarser 
articles  of  food,  sometimes  corned  beef  and  cabbage,  potatoes,  codfish, 
etc.,  and  it  is  very  often  the  general  diet  for  the  servants  and  attend- 
ants in  hospitals  as  well  as  patients. 


HOSPITAL  DIETARIES  863 

VI.  Articles  of  Special  Diet. —  Under  this  list  are  included  lux- 
uries and  delicacies,  such  as  oysters,  jellies,  custards,  gruels,  etc.,  and 
extra  allowances  of  eggs,  chicken,  cream,  and  fruits,  which  it  may 
be  desirable  to  furnish  in  individual  cases. 

With  a  system  arranged  upon  this  plan,  as  will  be  seen  by  the  ac- 
companying sample  tables,  used  in  some  of  the  representative  hos- 
pitals (pp.  868,  869),  the  ordering  of  the  diet  is  simplified  for  the 
visiting  physician  or  surgeon,  and  is  less  likely  to  be  relegated  by  him 
to  subordinates  than  it  is  if  he  be  obliged  to  spend  the  time  required 
for  selecting  a  separate  menu  for  each  patient  in  the  ward.  The  lim- 
itations of  each  classified  diet  should  be  distinctly  understood  by  all 
the  attendants  and  nurses,  and  a  printed  diet  list  of  articles  included 
under  the  headings  "  proteid  diet,"  "  special  diet,"  etc.,  should  be 
conspicuously  posted  in  the  ward  dining  or  service  rooms.  The  daily 
variations  within  the  limits  of  these  diets  should  be  regulated  by  the 
superintendent  of  the  hospital  or  purveyor,  whose  special  duty  is  to 
provide  the  food  for  the  institution,  and  select  such  articles  as  will 
afford  reasonable  variety,  due  allowance  being  made  for  fluctuations 
in  regard  to  price  and  season  of  the  year. 

In  many  large  hospitals  not  only  is  the  arrangement  of  the  diet 
imperfect,  but  the  details  of  preparing  and  serving  food  are  so  in- 
efficiently supervised  that  there  is  great  loss  from  waste  and  imper- 
fect cooking,  and  the  additional  expense  of  employing  a  specially 
trained  person  to  superintend  these  matters  would  be  more  than  coun- 
terbalanced by  the  saving  in  waste  and  in  added  benefit  to  the  patients. 
(See  Trained  Food  Purveyors,  p.  462.) 

Overfeeding. —  Too  much  food  is  often  given  hospital  patients  by 
overzealous  nurses,  who  are  anxious  to  hasten  convalescence.  This 
is  particularly  true  in  the  treatment  of  simple  surgical  cases  where 
there  is  no  special  digestive  disorder.  A  man  accustomed  to  doing 
eight  hours  of  active  physical  labor  when  put  to  bed  for  six  weeks  or 
more  with  his  leg  immobilized  for  a  fracture,  does  not  need  to  be  con- 
stantly stuffed  with  large  quantities  of  food,  and  yet  such  patients,  if 
the  matter  be  not  directed  carefully,  often  will  be  found  to  receive  full 
house  diet,  which  in  itself  is  ample  for  the  working  attendants  of 
the  hospital,  and  in  addition  a  quart  of  milk  a  day  as  a  beverage. 
The  natural  result  is  constipation,  indigestion,  with  a  heavily  coated 
tongue  and  more  or  less  "  biliousness,"  which  in  turn  is  counteracted 
by  a  compound  cathartic  pill  or  a  dose  of  calomel.  I  have  known  of 
night  nurses  going  through  wards  with  pitchers  of  milk,  and  pouring 
out  tumblerfuls  for  any  patients  who  were  at  all  thirsty,  quite  irre- 
spective of  any  supervision.  In  a  large  hospital,  where  the  monthly 


864  DIETARIES,   RATIONS 

consumption  of  milk  is  from  ten  to  fifteen  thousand  gallons,  it  read- 
ily may  be  seen  that  its  indiscriminate  use  as  a  beverage  is  an  item  of 
very  considerable  and  unnecessary  expense  to  the  institution,  besides 
being  an  actual  detriment  to  many  of  the  patients.  (See  Overeat- 
ing, p.  411.) 

Another  undesirable  tendency  among  American  hospital  dietaries 
is  to  include  far  too  much  meat.  The  ordinary  hospital  menu  com- 
pared, for  instance,  with  that  of  the  agricultural  laborer,  shows  this 
fact  very  strikingly.  Not  over  four  ounces  of  cooked  meat  (without 
bone)  need  be  allowed  in  the  meal  for  men.  In  the  house  diet  cheese 
and  legumes  may  be  substituted  in  great  part  economically. 

Fish  Diet. —  In  some  hospitals  in  addition  to  the  subdivisions  of 
the  diet  above  given,  a  "  fish  diet "  may  be  ordered,  which  is  very 
useful  and  should  be  adopted  generally.  In  the  London  Fever  Hos- 
pital this  diet  consists  of  a  ration  of  bread  (ten  ounces)  and  fish 
(eight  ounces,  uncooked  measure),  such  as  haddock,  cod,  or  sole,  or 
some  similar  fish,  potatoes  (eight  ounces),  cocoa  (one  ounce),  with 
half  an  ounce  of  sugar  and  a  sixth  of  a  pint  of  milk.  This  is  a  serv- 
iceable and  economical  diet  for  a  considerable  class  of  patients  for 
whom  large  quantities  of  meat  are  not  only  unnecessary  but  injurious. 

Broth  Diet. —  In  children's  hospitals  a  diet  is  sometimes  classified 
as  the  "  broth  diet,"  i.  e.,  mutton  broth  flavored  with  vegetables,  and 
bread  and  butter,  with  milk ;  or  a  "  beef-tea  diet/'  in  which  the  beef 
tea  replaces  the  broth;  and  in  the  lighter  diet  of  children,  gruels, 
bread  and  molasses,  and  simple  farinaceous  foods,  such  as  farina,  corn- 
starch,  rice,  etc.,  should  play  an  important  role.  Sometimes  such  diet 
goes  under  the  name  of  "  soft  food." 

In  German  hospitals  and  some  of  the  English  hospitals,  as  in  the 
London  Fever  Hospital,  beer  is  allowed  with  the  full  diet,  and  in  the 
latter  hospital  also  a  discrimination  is  made  in  ordering  the  diet  ac- 
cording to  sex,  females  being  given  from  two  to  four  ounces  less  bread 
and  two  to  three  ounces  less  meat  than  males.  This  distinction  is  not 
made  in  American  hospitals. 

Sample  Hospital  Dietaries 

DIETARY    OF    THE    NEW    YORK    HOSPITAL 

"  All  patients  shall  be  furnished  the  regular  house  diet,  unless 
otherwise  specially  directed  by  the  attending  physician  or  surgeon. 
As  a  substitute  for  the  house  diet,  there  may  be  furnished,  on  the 
order  of  the  attending  physician  or  surgeon  only,  either  of  the  fol- 
lowing: 1.  Eestricted  diet.  2.  Milk  diet. 


HOSPITAL  DIETARIES  865 

"The  attending  physician  or  surgeon  shall  specify,  on  the  occa- 
sion of  his  first  visit  to  a  patient,  which  diet  shall  be  furnished. 
This  duty  may  not  be  delegated  to  the  house  physician  or  house  sur- 
geon, except  that,  on  the  admission  of  a  patient  to  a  ward,  it  shall  be 
the  duty  of  either  to  give  instruction  on  the  subject  to  the  nurse  in 
charge,  and  such  instruction  shall  be  followed  until  the  first  visit  of 
the  attending  physician  or  surgeon. 

"The  wards  shall  be  supplied  with  blanks,  called  diet  lists.  The 
head  nurse  shall  carry  one  of  these  with  her  regularly  when  accom- 
panying the  attending  physician  or  surgeon  on  his  visits,  and  shall 
note  carefully  all  his  instructions  as  to  diet;  he  shall  sign  these  lists 
before  leaving  the  ward. 

"  Milk  diet,"  or  "  restricted  diet,"  may  not  be  ordered  in  addition 
to 'the  regular  house  diet,  but  only  as  a  substitute  therefor,  but  the 
attending  physician  or  surgeon  may  order  items  of  special  diet  in 
particular  cases. 

"  Lists  defining  the  different  classes  of  diet  shall  be  furnished  each 
attending  physician  and  surgeon. 

"  Cards,  appropriately  inscribed,  shall  be  placed  at  the  head  of 
each  bed,  which  shall  designate  the  class  of  diet,  and  also  the  amount 
of  stimulant,  which  is  furnished  each  patient. 

"  A  diet  kitchen  is  established,  under  the  direction  and  control  of 
the  directress  of  nurses,  wherein  articles  of  special  diet  shall  be  pre- 
pared and  served  as  ordered. 

"  Daily   House   Diet 

"  Breakfast. —  Oatmeal  or  hominy ;  tea  or  coffee,  with  milk  and 
sugar ;  bread  and  butter. 

"Dinner. —  Potatoes;  bread  and  butter;  one  or  more  of  the  fol- 
lowing vegetables :  turnips,  sweet  potatoes,  beets,  spinach,  squash. 

"Supper. —  Tea  with  milk  and  sugar;  bread  and  butter;  stewed 
or  fresh  fruit. 

"In  addition  on  Sunday. —  Breakast:  eggs.  Dinner:  roast  beef; 
cornstarch  pudding.  Monday. —  Breakfast:  baked  potatoes.  Din- 
ner: stock  soup,  stewed  beef  or  mutton,  rice  pudding.  Tuesday. — 
Breakfast:  mutton  chops.  Dinner:  pea  soup,  roast  mutton,  bread 
pudding.  Wednesday. —  Breakfast:  fried  or  stewed  potatoes.  Din- 
ner: roast  beef,  cornstarch  pudding.  Thursday. —  Breakfast:  eggs. 
Dinner:  stock  soup,  stewed  beef  or  mutton,  tapioca  pudding.  Fri- 
day.—  Breakfast :  salt  mackerel  or  codfish.  Dinner :  bean  soup,  baked 
fish,  beans,  rice  pudding.  Saturday. —  Breakfast:  beefsteak.  Din- 
ner :  corned  beef,  cabbage,  bread  pudding. 
57 


866  DIETARIES,   RATIONS 

"  Restricted  Diet 

"Breakfast. —  Tea  or  coffee  (with  milk  and  sugar),  farinaceous 
food  (with  milk),  eggs. 

"  Dinner. —  Soup ;  either  of  the  following :  raw  oysters,  roast  beef, 
steak,  chicken  with  vegetables,  pudding  (bread,  rice,  tapioca,  or  corn- 
starch). 

"Supper. —  Tea  (with  milk  and  sugar),  bread  (with  butter),  fruit 
(fresh  or  dried). 

"Milk  Diet 

"  Six  pints  of  milk  daily. 

"Articles  of  Special  Diet 

"  Milk,  eggs,  beef  tea,  oysters,  cornstarch,  chops,  steak,  chicken, 
chicken  soup,  rice,  broth,  farina,  ice  cream,  as  ordered  by  the  attend- 
ing physician  or  surgeon. 

"  Salt  fish,  jellies,  custards,  gruels." 

At  the  New  York  Hospital  a  carefully  graduated  diet  list,  made 
out  in  ounces  per  capita,  was  formerly  used,  but  it  was  found  both 
unnecessary  and  impractical.  Separate  tables  are  laid  for  the  pa- 
tients, nurses,  and  servants;  but  the  amount  of  food  is  estimated  in 
a  general  way,  the  terms  being  based  rather  upon  the  cost  price  per 
capita  than  upon  the  number  of  ounces,  and  it  is  proportioned  by  the 
housekeeper  and  her  assistants  with  due  regard  to  economy. 

DIETARY    IN    BELLEVTJE,    GOUVERNEUR,    FORDHAM,    AND    HARLEM 
HOSPITALS,    NEW    YORK 

Monday 

Breakfast. —  Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half  an  ounce 
of  sugar;  bread,  five  and  one-third  ounces,  and  a  quarter  of  an  ounce  of 
butter;  oatmeal,  one  ounce;  crackers,  one  ounce;  milk,  one  quart. 

Dinner. —  Roast  beef,  eight  ounces;  rice,  one  ounce;  soup,  one  pint;  po- 
tatoes, eight  ounces;  vegetables,  four  ounces;  bread. 

Supper. —  Tea,  one  pint,  with  half  an  ounce  of  milk  and  half  an  ounce  of 
siurar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce  of  butter; 
one  ounce  of  stewed  apples. 

Tuesday 

Breakfast. —  Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half  an 
ounce  of  sugar;  bread,  five  and  one-third  ounces,  and  a  quarter  of  an  ounce 
of  butter ;  hominy,  one  ounce ;  crackers,  one  ounce ;  milk,  one  quart. 

Dinner. —  Mutton  stew,  eight  ounces ;  potatoes,  eight  ounces ;  vegetables, 
four  ounces;  bread,  five  and  one-third  ounces;  bread  pudding,  two  and  a  half 
ounces. 

Xuppcr. —  Tea.  one  pint,  with  half  an  ounce  of  milk  and  half  an  ounce  of 
sugar;  bread,  five  and  one-third  ounces;  butter,  a  quarter  of  an  ounce. 


HOSPITAL  DIETARIES  867 

Wednesday 

Breakfast. —  Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half  an  ounce 
of  sugar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce  of 
butter;  rice,  one  ounce;  crackers,  one  ounce;  milk,  one  quart. 

Dinner. —  Roast  beef,  eight  ounces;  barley  soup,  one  pint;  potatoes,  eight 
ounces;  bread,  five  and  one-third  ounces. 

Supper. —  Tea,  one  pint,  with  half  an  ounce  of  milk  and  half  an  ounce  of 
sugar;  bread,  five  and  one-third  ounces,  and  a  quarter  of  an  ounce  of  butter; 
stewed  prunes,  one  ounce. 

Thursday 

Breakfast. —  Coffee,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce 
of  sugar;  five  and  one  third  ounces  of  bread  and  a  quarter  of  an  ounce  of 
butter;  oatmeal,  one  ounce;  crackers,  one  ounce;  milk,  one  quart. 

Dinner. —  Beef  stew,  eight  ounces ;  potatoes,  eight  ounces ;  vegetables,  four 
ounces;  bread,  five  and  one-third  ounces. 

Supper. —  Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce  of 
sugar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce  of  butter; 
one  ounce  of  stewed  apples. 

Friday 

Breakfast. —  Coffee,  one  pint,  with  half  an  ounce  of  milk  and  half  an 
ounce  of  sugar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce 
of  butter;  two  eggs;  crackers,  one  ounce;  milk,  one  quart. 

Dinner. —  Baked  fish,  eight  ounces;  potatoes,  eight  ounces;  vegetables,  four 
ounces;  bread,  five  and  one-third  ounces;  rice  pudding,  two  and  a  half  ounces. 

Supper. —  Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce  of 
sugar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce  of  butter. 

Saturday 

Breakfast. —  Coffee,  one  pint,  with  a  quarter  of  a  pint  of  milk  and  a 
quarter  of  an  ounce  of  sugar;  five  and  one-third  ounces  of  bread  and  a  quar- 
ter of  an  ounce  of  butter;  hominy,  one  ounce;  crackers,  one  ounce;  milk,  one 
quart. 

Dinner. —  Mutton  stew,  eight  ounces;  potatoes,  nine  ounces;  vegetables, 
four  ounces;  bread,  five  and  one-third  ounces. 

Supper. —  Tea,  one  pint,  with  milk  half  a  pint,  and  half  an  ounce  of  sugar; 
bread,  five  and  one-third  ounces;  butter,  a  quarter  of  an  ounce;  stewed  prunes, 
one  ounce. 

Sunday 

Breakfast. —  Coffee,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce  of 
sugar;  five  and  one-third  ounces  of  bread  and  a  quarter  of  an  ounce  of  butter; 
crackers,  one  ounce;  milk,  one  quart;  two  eggs. 

Dinner. —  Corned  beef,  eight  ounces;  bean  soup,  one  pint;  potatoes,  eight 
ounces;  bread,  five  and  one-third  ounces;  cornstarch  pudding,  two  and  a  half 
ounces. 

Supper. —  Tea,  one  pint,  with  half  a  pint  of  milk  and  half  an  ounce  of 
sugar-  bread,  five  and  one-third  ounces,  and  butter,  a  quarter  of  an  ounce. 

Uilk  Diet 

To  be  prescribed  by  attending  physicians  or  surgeons. 
Articles  of  Special  Diet 


soup 


Beefsteak,  half  a  pound;  beef  tea,  one  pint;  chicken,  half  a  pound;  chicken 
up,  one  pint;  rice  and  milk,  one  pint;  two  eggs;  milk,  one  quart. 


868 


DIETARIES,  RATIONS 


DIETARY  OF  THE  PRESBYTERIAN  HOSPITAL,  NEW  YORK,  1909. 

Although  the  diet  is  very  satisfactory  and  ample  at  the  Presby- 
terian Hospital,  New  York,  the  food  allowance  per  capita  for  patients 
is  not  separately  estimated,  and  the  house  diet,  convalescent  diet, 
and  diet  for  the  servants  on  pages  870,  871  are  all  originally  pre- 
pared in  bulk,  and  subsequently  subdivided  by  the  cooks  and  nurses 
under  the  order  of  the  visiting  physicians  and  surgeons,  but  without 
regard  to  accurate  measurement  of  quantity  in  ounces  much  less 
in  "  calories."  In  fact,  the  latter  method  of  calculation  is  rarely 
used  in  American  institutions,  practical  experience  usually  being  pre- 
ferred. 

The  diet  sheet  printed  below  is  in  daily  use  in  the  wards  at  the 
Presbyterian  Hospital,  New  York  City,  where  it  has  proved  very  satis- 
factory. It  will  be  observed  that  it  is  properly 'classified  according  to 
quality,  but  not  as  to  quantity.  It  was  introduced  several  years 
ago  after  a  careful  comparison  with  diets  of  other  institutions,  and 
it  has  proved  very  practical.  It  is  the  most  liberal  and  the  most 
conveniently  classified  diet  of  any  hospital  with  which  I  am  fa- 
miliar. 

The  following  two  diet  sheets  are  to  be  filled  and  signed  by  the 
medical  staff  daily: 

THE  PRESBYTERIAN  HOSPITAL 
Extra  Diet  Sheet 


Medical  Division     Ward  No.. 


New  York 1906 


NAME. 

BREAKFAST. 

DINNER. 

SUPPER. 

Milk  Toast 

12 

Chicken 

12 

Milk  Toast 

12 

Toast 

10 

Chops 

4 

Toast 

10 

Chops 

6 

Rice 

15 

Chops 

6 

Lemons 

8 

Custard 

15 

Custard 

15 

Eggs 

46 

Baked    Apples 

4 

Baked  Apples 

6 

Scraped  Beef 

9  oz. 

Raw  Oysters 

6 

Chopped  Beef 

4  Ibs. 

Chicken  Broth  4 

pts 

Pressed  Beef  Juice 

7  oz. 

Baked  Potatoes 

6 

Milk 

1  can 

Milk                   1 

can 

Milk              2 

cans 

TOTAL 


Attending  Physician:   Surgeon 


House  Physician:   Surgeon 


HOSPITAL  DIETARIES 


869 


CO 

i      § 

1—  1 

8       8 

SC           6jD 

c        o" 

iy           *y 
S^         "co 

s     £ 

I 

'-3        § 

1     w 

fe 

1   • 

4) 
P 

PH 
03 
O 
W 

S               -g 

1    5   S 

<     a 

•i    £    Js 

PH      03 

S 

H     g 

O 

S     0 
03 

1 

PH 

<*- 

o 

1 

6     z      ~ 

5   1 

e 

-s    « 

•"2      I      o 

3 

•S 

o      g     5 

fe 

•g 

1 

NAMES  OK  PATIENTS. 

2 

-3 

aa 

o 

w 

Convalescent  diet  .  .  . 

Nitrogenous  diet  .... 

Farinaceous  diet  .... 

2 

'-3 

i 

2 

'-3 

hi 

•M 

S    o    !^ 
o 

cc 

-4-1 

^ 

PH 

«*- 

0 

O       ^         S 

!Z5 

870 


DIETARIES,   RATIONS 


THE  PRESBYTERIAN  HOSPITAL 

IN  THE  CITY  OF  NEW  YORK 

PATIENTS'  DIETARY 


HOUSE   DIET. 

CONVALESCENT 
DIET. 

NITROGENOUS 
DIET. 

Breakfast. 

Breakfast. 

Breakfast. 

Tea    or    Coffee     (Milk    and 

Tea    or    Coffee     (Milk    and 

Tea    or    Coffee    (Milk) 

Sugar) 

Sugar) 

Bread    and    Butter  — 

Bread   and   Butter  — 

Bread  and   Butter  — 

Graham    Bread 

White    Bread    or    Graham 

White    Bread    or    Graham 

Bread    or    Corn    Bread   or 

Bread   or    Corn    Bread    or 

Meats  — 

Rolls   or  Toast 

Rolls    or    Toast 

Eggs    or    Fresh    Fish    or 

Porridge  — 

Porridge  — 

Stew    without    Vegetables 
or     Meat     Hash     without 

Oatmeal        or        Wheaten 

Hominy  or  Farina 

Potatoes 

grits    or    Indian    Meal    or 
Hominy    or    Farina 

Meats  — 

Eggs    or    Fresh    Fish    or 

Meats  — 

Stew    (plain) 

Hash     or     Eggs     or     Salt 

Fish    or    Fresh    Fish    or 

Stew 

Dinner. 

Dinner. 

Dinner. 

Soup  — 

Soup  — 

Soup  — 

Stock    or    Mutton    Broth 

Stock      or      Chicken      or 

Stock  or  Chowder 

with    barley    or  vegetable 
or    Chowder 

Mutton    Broth    with    bar- 
ley  or   vegetable 

Graham    Bread 

Dry    Bread 

Dry  Bread 

Meats  — 

Meats  — 

Meats  — 

Beef     (Roast    or    Boiled) 
or      Mutton      (Roast      or 

Beef     (Roast    or    Boiled) 

Beef     (Roast    or    Boiled) 

Boiled)    or  Fresh  Fish  or 

or      Mutton       (Roast      or 

or       Chicken       or       Fish 

Irish    Stew 

Boiled)     or    Corned    Beef 
or    Fresh    Fish    or    Irish 
Stew 

(Fresh) 
Vegetables  — 

Vegetables  — 
Spinach     or     Lettuce     or 

Vegetables  — 
Potatoes     (Baked,     Boiled 

Potatoes     (Baked,    Boiled 
or      Mashed),       Rice      or 
Macaroni    or    Hominy 

Celery  or  String  Beans 
Pudding  — 

or     Mashed)     and    Toma- 
toes   or    Baked    Beans    or 

Pudding  — 

Custard 

French   Beans   or   Turnips 

Rice    or    Bread    or    Tapi- 

or  Beets  or  Rice   or   Ma- 

oca   or    Farina     or    Corn 

caroni   or   Hominy 

Starch    or    Custard 

Pudding  — 

Rice    or    Bread    or    Tapi- 

oca    or    Farina    or    Corn 

Starch   or   Custard 

Supper. 

Supper. 

Supper. 

Tea    (Milk    and    Sugar) 

Tea    (Milk    and    Sugar) 

Tea    (Milk) 

Bread      and      Butter      or 

Bread   and    Milk   or   Milk 

Graham    Bread    and    But- 

Toast   and    Butter 

Toast   or  Bread   and  But- 

ter   or    Bread    and    Milk, 

ter    or   Toast    and   Butter 

Eggs  or  Cold  Meat 

Fruit  — 

Apples           (Stewed          or 

Fruit  — 

Raked)      or      Prunes      or 

Apples          (Stewed          or 

Pears 

Baked)      or      Prunes      or 

Pe^rs 

HOSPITAL   DIETARIES 


871 


(PRESBYTERIAN  HOSPITAL  DIETARY  —  Continued.) 


FARINACEOUS 
DIET. 

MILK   DIET. 

Typhoid    Fluid    Diet. 

Breakfast. 

Tea    or    Coffee     (Milk    and 
Sugar) 

Bread   and  Butter  — 
White    Bread    or    Graham 
Bread   or    Corn    Bread   or 
Rolls    or    Toast 

Porridge  — 
Hominy  or  Farina  or  In- 
dian  Meal 

Dinner. 

Soup  — 
"Vegetable  or  Macaroni  or 
Barley    Broth 

Dry  Bread 

Vegetables  — 
Baked    Potatoes    and    To- 
matoes   or    French    Beans 
or    Rice    or    Macaroni    or 
Hominy 

Pudding  — 
Rice  or  Bread  or  Tapioca 
or  Farina  or.  Corn   Starch 

Supper. 

Tea     (Milk    or    Sugar) 
Bread    and   Milk   or   Milk 
Toast       or      Hominy      or 
Boiled    Rice    or   Farina 

Fruit  — 
Apples          (Stewed          or 
Baked)      or      Prunes      or 
Pears 

Breakfast 

One    quart    of    milk 

Dinner. 

One    quart    of    milk 

Supper. 

One    quart    of    milk 

Milk,    Broth,    Egg    Albumen 

Typhoid  Delicacies. 

Hice     (well     cooked),     Jun- 
ket,       Custard,        Gruels, 
Milk  Toast,  Scraped  Beef, 
Eggs 

Typhoid  Extra  Diet. 

Broths,     Beef     Soups,     Oys- 
ters,    White      Fish,    Beef 
Chops,        Mutton       Steak, 
Custard,     Egsrs,     Chicken, 
Rice,  White  Bread,  Toast, 
Farinaceous    Puddings. 
No    Vegetables,    Fruit,    Pas- 
try   or    Hot    Bread. 

FLUID  DIET. 

Milk,     Beef     Tea,      Chicken 
Broth,       Mutton       Broth. 
Egg   Albumen 

SOFT  DIET. 

Cereals,    Eggs,    Milk    Toast, 
Custard,             Farinaceous 
Puddings,      Tea,      Coffee, 
Milk 

After     Two     Days     of 
Normal    Temperature. 

Strained    Vegetable     Soups, 
Baked  Apples,   Baked  Po- 
tatoes,  Oatmeal 

EXTRAS. 

Ordered     only     by     the     at- 
tending Physician  or  Sur- 
geon. 
Mutton    Chops,    Beef   Steak, 
Scraped    Beef,    Beef    Tea 
(made   with   Hydrochloric 
Acid),    Chicken    (Broiled, 
Fricasseed      or       Roast), 
Chicken       Broth,        Eggs, 
Milk,        Oysters,        Clam 
Broth,    Gruels,    Crackers, 
Gingerbread,           Custard, 
Milk    Toast 

DIABETIC  DIET. 

Buttermilk,    Koumyss,    Beef 
Tea,    Coffee,    Cocoa,    Tea, 
Saccharin      in      lieu      of 
sugar,   Clams,    thin    soup, 
Fish,   Poultry,   Beef,   Mut- 
ton,   Bacon,    Eggs,    String 
Beans,      Cabbage,      Toma- 
toes,     Lettuce,      Spinach, 
Greens,     Lemons,    Apples. 
Oranges,    Strawberries 
No   Milk   or   Sugar 

The    Fresh    Fruit    and    Vegetables   above    specified   will   be    furnished  only 
season." 


872 


DIETARIES,   RATIONS 


DIETAKY   OF    THE   ALLEGHENY    (PENNSYLVANIA)    GENERAL 

HOSPITAL 


Liquids,  semi-liquids  (without 
starch  and  sugar),  soft  or  light, 
selected  house. 

I.   LIQUID. 

(a)  Milk  — 

Modified  Milk. 

Whey. 

Koumiss. 

Laban. 

Milk  Jelly   (Irish  Moss). 

(I)  Meat  Foods  — 
Beef  Juice. 
Beef  Tea. 
Beef  Broth. 
Consomme. 
Bouillon. 

Beef  Jelly    (Gelatine). 
Beef  Jelly    (Irish  Moss). 
Mutton  Juice  and  Broth. 
Chicken  Broth  and  Jelly. 
Clam  Broth  and  Juice. 
Oyster  Broth  and  Juice. 

LIQUID    FOODS   FBOZEN. 

(c)  Starchy  Liquid  Foods. 

(d)  Cream  — 

II.  SEMI-LIQUIDS. 

(Without  Starch  and  Sugar.) 
Liquid   Food. 
Gluten  Gruel. 
Irish  Moss  Gruel. 
Irish  Moss  Chicken  Jelly. 
Irish  Moss  Thickening  for  soups 
and  sauces. 

Soups  — 

Chicken  Broth,  Croutons,  Egg. 

Consomme  and  Egg. 

Irish  Moss  Thickening  for 
soups  and  sauces. 

Oyster,  Thickened  with  Yolk 
'of  Egg. 

Chicken  Puree. 

Cream  of  Celery  Soup  Thick- 
ened with  Yolk  of  Egg. 

Clam,  Thickened  with  Yolk  of 
Egg- 

Sweetbread  Puree. 


Tomato,     using     Irish     Moss 

Thickening. 

Egg,  Poached,  Soft  Boiled. 
Beef  Paste. 

III.    SOFT    OB    LIGHT    DIET. 

Cereals. 

Cream  Soups. 

Egg  —  Soft     Boiled,     Poached, 

Omelette. 
Zwieback. 
Oysters. 
Chicken  Puree. 
Sweetbreads  Puree. 
Stewed  Fruits. 
Jellies. 

Soft  Desserts. 
Ice   Cream. 
Ices. 

Milk  Toast. 
Cream   Toast. 
Oranges    and    Grape    Fruit. 

IV.   SELECT    DIET. 

Soups  — 
Meats  — 

Beef  —  Broiled,  Baked. 

Lamb  —  Broiled,  Baked. 

Chicken. 

Fish  and  Oysters. 

Eggs. 

Vegetables  — 
Potatoes. 
Lettuce. 
String  Beans. 
Spinach. 
Squash. 
Tomatoes. 
Peas. 

Asparagus. 
Water  Cress. 
Celery. 

Light  Desserts  — 
Toast. 
Oranges. 

V.  HOUSE. 
Pastry  and  Fried  Foods  omitted. 


DIETARY  OF  THE  ROOSEVELT  HOSPITAL,  NEW  YORK 

The  ward  diet  of  the  Eoosevelt  Hospital,  New  York  city,  is  classified 
as  follows: 

Full  Diet 

Dally. —  Meat,  dressed,  eight  ounces;   potatoes,  eight  ounces;   bread,  twelve 
ounces;  butter,  one  ounce;  sugar,  two  ounces  and  a  half;  milk,  half  a  pint; 


HOSPITAL  DIETARIES  873 

coffee,  half  an  ounce;  tea,  an  eighth  of  an  ounce.  On  Sundays,  Tuesdays, 
and  Thursdays,  other  vegetables  in  addition  to  potatoes,  two  ounces;  bread, 
rice,  or  tapioca  pudding.  On  Mondays  and  Wednesdays,  soup,  one  pint. 
On  Fridays,  fish. 

Breakfast. —  Coffee  with  sugar  and  milk,  bread  and  butter,  porridge  of 
oatmeal,  wheaten  grits,  or  samp. 

Dinner. —  Sunday :  Roast  beef,  potatoes,  tomatoes,  or  other  vegetable, 
bread,  and  bread  pudding.  Monday:  Soup,  boiled  mutton,  potatoes,  and 
bread.  Tuesday:  Corned  beef  twelve  ounces;  cabbage  or  turnips,  pota- 
toes and  bread.  Wednesday:  Soup,  roast  beef,  potatoes  and  bread.  Thurs- 
day: Soup,  boiled  beef,  potatoes,  onions,  tapioca,  sago,  or  farina  pudding, 
and  bread.  Friday:  Fish,  boiled  or  roast  beef,  potatoes,  bread,  boiled  rice 
sweetened  with  sugar  and  milk,  and  raisins.  Saturday:  Stew  of  mutton, 
potatoes  and  bread. 

Supper. —  Tea  with  sugar  and  milk,  bread  and  butter,  baked  apples,  or 
stewed  pears,  or  prunes,  or  green  or  dried  apple  sauce,  and,  on  Sundays, 
gingerbread  varied,  alternate  weeks,  with  currant  buns. 

Half  Diet 

Daily. —  Meat,  dressed,  four  ounces;  potatoes,  four  ounces;  bread,  six 
ounces;  of  other  articles,  the  same  as  in  full  diet. 

Milk  Diet 

Daily. —  Milk,  two  pints ;  bread,  twelve  ounces ;  rice  or  samp,  two  ounces ; 
butter,  one  ounce. 

Extras 

In  addition  to  the  above,  the  following  extras  may  be  ordered  by  the  visit- 
ing physicians  and  surgeons:  Beefsteak,  chicken  soup,  gruel,  beef  tea,  oysters 
or  clams,  cornstarch,  mutton  chops,  milk,  rice,  chicken,  eggs. 

NOTE. —  This  dietary  is  estimated  in  ounces  on  paper,  but  the  food  is  not 
weighed  out  for  any  patient. 

DIETARY  OF  THE  JOHNS  HOPKINS  HOSPITAL,  BALTIMORE 

At  the  Johns  Hopkins  Hospital  the  Free  Ward  Diet  is  liberal,  but 
no  attempt  is  made  to  classify  the  food  qualitatively  as  served  to  the 
wards.  A  sample  Sunday  menu  given  there  is  the  following.  It  is 
expensive,  owing  to  the  excess  of  animal  food : 

Breakfast. —  Corned-beef  hash,  oatmeal,  toast,  eggs,  bread  and  butter,  coffee 
or  tea,  and  milk. 

Dinner. —  Soup,  roast  beef,  potatoes,  rice,  turnips,  toast,  pudding  and  milk, 
bread  and  butter. 

Supper. —  Cold  roast  beef  or  pressed  corned  beef,  bread  and  butter,  coffee  or 
tea,  and  milk. 

DIETARY  OF  THE  COOK  COUNTY  HOSPITAL,  CHICAGO 

In  the  Cook  County  Hospital,  of  Chicago,  the  official  diets  are  four 
—  viz.,  ward  diet,  light  diet,  special  diet,  milk.  Extras  may  be  or- 
dered, such  as  chicken,  chops,  beefsteak,  eggs,  cream,  crackers,  lemons, 
or  additional  butter,  milk,  sugar,  sirup,  and  vinegar.  Here  again  no 
special  attempt  is  made  to  classify  foods  qualitatively. 

Following  is  a  sample  midsummer  diet,  from   a   small  hospital, 
having  about  seventy  beds,  in  which  attention  is  economically  given 
58 


874  DIETARIES,   RATIONS 

to  variety  in  food  cookery  which  would  be  impossible  in  a  larger  in- 
stitution without  incurring  needless  expense: 

WARD  DIETARY  OF  THE  NEW  YORK  INFIRMARY  FOR  WOMEN  AND 

CHILDREN 
Sunday 

Breakfast. —  Full  Diet :  Hominy  with  milk,  fish  balls  or  creamed  fish, 
brown  bread  or  biscuit,  coffee  with  milk  and  sugar,  fresh  fruit.  Half  Diet: 
Hominy  with  milk,  toast,  coffee,  fresh  fruit. 

Dinner. —  Full  Diet :  Soup,  bread,  roast  beef,  sweet  or  white  potatoes, 
spinach  or  egg  plant,  pudding.  Half  Diet:  Clam  broth,  toast,  chicken  or 
beef  jelly,  rice,  or  ice  cream. 

Supper. —  Full  Diet :  Pressed  beef  or  cream  salmon,  bread  and  butter,  cocoa. 
Half  Diet:  Indian  meal  porridge  and  milk,  toast,  cocoa,  fruit. 

Monday 

Breakfast. —  Full  Diet :  Oatmeal  and  milk,  bread  and  butter,  poached 
eggs  on  toast,  coffee  with  milk  and  sugar.  Half  Diet:  Oatmeal,  eggs  on 
toast,  coffee,  fresh  fruit. 

Dinner. —  Full  Diet :  Soup,  bread,  roast  lamb,  spaghetti,  tomatoes  or  lima 
beans,  rice  pudding  or  prune  pudding  or  cottage  pudding.  Half  Diet: 
Chicken  broth,  toast,  spaghetti,  rice  pudding  or  cottage  pudding. 

Supper. —  Full  Diet:  Baked  potatoes  and  bacon  or  creamed  beef  or  toast, 
bread  and  butter,  tea,  fruit.  Half  Diet:  Hominy  and  milk,  bread  and  butter 
or  toast,  tea,  fruit. 

Tuesday 

Breakfast. —  Full  Diet:  Wheat  flakes  and  milk,  beef  mince  or  hash,  bread 
and  butter,  coffee.  Half  Diet:  Wheat  flakes,  buttered  toast,  coffee,  fresh  fruit. 

Dinner. —  Full  Diet :  Soup,  bread,  steak,  cresses,  potatoes,  beans  or  carrots 
or  beets,  boiled  or  baked  custard  or  ice  cream.  Half  Diet:  Mutton  broth, 
rice,  toast,  custard  or  ice  cream. 

Supper. —  Full  Diet :  Brown  bread  and  butter,  cream  cheese  or  boiled 
eggs  or  sliced  beef,  fruit,  cocoa.  Half  Diet:  Oatmeal  jelly  and  milk,  toast, 
fruit,  cocoa. 

Wednesday 

Breakfast. —  Full  Diet:  Hominy  with  milk,  lamb  mince  or  lamb  with 
cream  sauce,  bread,  butter,  coffee.  Half  Diet:  Hominy  with  milk,  buttered 
toast,  boiled  eggs,  coffee,  fresh  fruit. 

Dinner. —  Full  Diet:  Soup,  bread,  chicken,  potatoes  or  rice,  peas,  tapioca 
or  fruit  pudding  or  custard.  Half  Diet:  Broth,  rice,  toast,  tapioca. 

Supper. —  Full  Diet :  Spaghetti  and  tomato  or  sliced  tomatoes  or  baked 
corn,  bread  and  butter,  tea,  fruit.  Half  Diet:  Wheat  flakes  and  milk,  toast, 
tea,  fruit. 

Thursday 

Breakfast. —  Full  Diet:  Oatmeal  and  milk,  fresh  fish,  bread  and  butter, 
coffee.  Half  Diet:  Oatmeal  and  milk,  toast,  coffee,  fresh  fruit. 

Dinner. —  Full  Diet:  Soup,  bread,  braised  beef,  macaroni,  spinach  or  string 
beans,  wine  jelly  or  fruit  jelly.  Half  Diet:  Chicken  broth,  macaroni,  toast, 
wine  jelly. 

Supper. —  Full  Diet:  Beef  stew  or  cream  toast  or  pea  soup,  bread  and  but- 
ter, cake,  fruit,  cocoa.  Half  Diet:  Cream  toast,  cocoa,  fruit. 

Friday 

Breakfast. —  Full  Diet:  Wheat  flakes  and  milk,  scrambled  eggs  on  toast, 
bread  and  butter.  Half  Diet:  Wheat  flakes  and  milk,  eggs,  toast,  coffee,  fresh 
fruit. 


HOSPITAL   DIETARIES 


875 


Dinner. —  Full  Diet :  Soup,  bread,  fish,  potatoes,  tomatoes  or  peas,  bread 
pudding  or  Indian  pudding  or  ice  cream.  Half  Diet:  Lamb  broth,  rice,  bread 
pudding  or  ice  cream. 

Supper. —  Full  Diet :  Chowder  or  boiled  eggs,  bread  and  butter,  tea,  fruit. 
Half  Diet:  Oatmeal  jelly,  toast,  tea,  fruit. 

Saturday 

Breakfast. —  Full  Diet:  Indian  meal  porridge  and  maple  sirup  or  milk, 
beef  ragout,  bread  and  butter,  coffee.  Half  Diet:  Indian  porridge,  toast, 
coffee. 

Dinner. —  Full  Diet:  Soup,  bread,  steak,  potatoes,  cauliflower  or  squash. 
Half  Diet:  Chicken  broth,  toast,  rice,  rennet  custard,  blancmange. 

Supper. —  Full  Diet:  Lamb  stew  or  baked  beans,  bread  and  butter,  tea, 
fruit.  Half  Diet:  Wheat  flakes  and  milk,  toast,  tea,  fruit. 

Food  which  may  be  ordered  by  resident  or  attending  physicians  when 
daily  diet  is  not  adequate  or  suitable: 

Beefsteak,  chops,  chicken,  beef  jelly,  chicken  jelly,  scraped  beef  balls, 
raw  beef  sandwiches,  clam  broth,  crackers,  extra  eggs  and  milk,  gruels,  oat- 
meal jelly,  wine  or  fruit  jelly,  cold  beef  extract  made  with  hydrochloric  acid. 
In  this  same  institution  is  given  the 

Average  Daily  Dietary  for  Adult  Women  Patients,  not  including  Milk,  Eggs, 
or  Beef  Tea  for  Special  Cases 

Flour,  meal,  rice,  or  beans,  uncooked  J  ounce. 

Bread   8  ounces. 

Butter  and  fat    2J  " 

Sugar  , 2  " 

Breakfast  cereals,  uncooked   1  ounce. 

Meat  or  _fish,  dressed  but  uncooked   8  ounces. 

Potatoes,  dressed  but  uncooked   5  to  6  " 

Fresh  or  canned  vegetables,  cooked   4  to  5  " 

Stewed  or  fresh  fruit,  prepared  or  cooked 3  to  4  " 

Soup    |  pint  or     8  " 

Milk    1  .  "  "16 

Coffee   &      "  "      8  " 

Tea  or  cocoa   J      "  "      8  " 

Eggs,  one  every  other  day J  ounce. 

NEW   YORK   STATE   HOSPITAL PROPOSED   DIETARY 

Austin  Flint  recommended  the  following  dietary  and  food  supply 
for  the  New  York  State  Hospital : 

"  The  table  is  intended  for  patients  not  upon  extra  diet  and  attend- 
ants only,  and  I  have  suggested  that  25  per  cent  in  the  rations  of 
meat,  flour,  and  potatoes  be  added  for  workers." 

NEW  YORK  STATE  HOSPITAL 

Daily  Ration 
Meat,  with  bone,  including  salted  meats,  fresh  and  salted 

fish,  and  poultry    12     ounces. 

Flour,  to  be  used  in  making  bread  and  in  cooking  ( may  in 

part  be  substituted  by  cornmeal  and  macaroni )    12 

Potatoes    12         " 

Milk 16 

One  egg    2 

Sugar    2 

Butter   2 

Cheese  1 

Rice,  hominy,  or  oatmeal   1J 

Beans  or  peas    ( dried ) 1 J 

Coffee   ( in  the  berry  and  roasted)    i 

Tea    (black)     i 


876  DIETARIES,   RATIONS 

Supplies  for  One  Hundred  Persons  for  Thirty  Days 

Meat,  with  bone,  including  salted  meat,  fresh  and  salted 

fish,  and  poultry,  total  2,250  pounds. 

Flour    (may  be  in  part  substituted  by  cornmeal  and 

macaroni )     2,250       " 

Potatoes    2,250       " 

Milk 1,500  quarts. 

Eggs    250  dozen. 

Sugar    490  pounds. 

Butter   430 

Cheese   215 

Rice   108 

Hominy  108 

Oatmeal    108 

Coffee    180 

Tea    26 

"  Flour  should  be  interchangeable,  on  this  basis,  with  potatoes, 
rice,  hominy,  and  oatmeal.  Butter  and  cheese  may  be  interchange- 
able in  the  proportion  of  one  pound  of  butter  to  two  pounds  of 
cheese;  and  eggs  and  milk,  in  the  proportion  of  two  eggs  to  one  pint 
of  milk.  There  are  occasions  when  eggs  may  be  substituted  with 
advantage  for  meat.  This  may  be  done  on  the  basis  of  eight  eggs 
for  one  pound  of  meat.  When  fruits,  fresh  and  dried,  are  used  in 
abundance,  a  reduction  may  be  made  in  eggs,  butter,  cheese,  and  milk." 

DIETARY  OF  THE  TJTICA  STATE  HOSPITAL,  FOR  THE  INSANE 

Monday 

Breakfast. —  Cold  corned  beef,  oatmeal,  boiled  potatoes,  bread  and  butter, 
tea  or  coffee. 

Dinner. —  Roast  beef,  boiled  potatoes,  gravy,  boiled  rice,  bread  and  butter, 
tea. 

Supper. —  Roll,  bread,  sirup,  butter,  tea. 

Tuesday 

Breakfast. —  Cold  roast  beef,  oatmeal,  boiled  potatoes,  bread  and  butter, 
tea  or  coffee. 

Dinner. —  Vegetable  soup,  boiled  mutton,  boiled  potatoes,  bread  and  butter, 
and  tea. 

Supper. —  Molasses  cookies,  bread  and  butter,  tea. 

Wednesday 

Breakfast. —  Roast  mutton,  oatmeal,  boiled  potatoes,  bread  and  butter,  tea 
or  coffee. 

Dinner. —  Roast  veal,  boiled  potatoes,  Indian  pudding,  gravy,  bread  and 
butter,  tea. 

Supper. —  Stewed  prunes,  bread  and  butter,  tea. 

Thursday 

Breakfast. —  Cold  roast  veal,  oatmeal,  boiled  potatoes,  bread  and  butter, 
tea  or  coffee. 

Dinner. —  Baked  salt  pork,  baked  beans,  boiled  potatoes,  bread  and  butter, 
tea. 

Supper. —  Cheese,  roll,  bread,  sirup,  butter,  tea. 

Friday 

Breakfast. —  Codfish,  oatmeal,  boiled  potatoes,  bread  and  butter,  tea  or  coffee. 

Dinner. —  Fresh  fish,  boiled  potatoes,  dried  raspberry  pie,  bread  and  butter, 
tea. 

Supper. —  Sugar  cookies,  bread  and  butter,  tea. 


HOSPITAL  DIETARIES  877 

Saturday 

Breakfast. —  Cold  roast  beef,  oatmeal,  boiled  potatoes,  bread  and  butter, 
tea  or  coffee. 

Dinner. —  Corned  beef,  boiled  cabbage,  boiled  "potatoes,  bread  and  butter,  tea. 

Supper. —  Corn  and  wheat  bread,  cheese,  butter,  tea. 

Sunday 

Breakfast. —  Boiled  eggs,  oatmeal,  boiled  potatoes,  bread  and  butter,  tea  or 
coffee. 

Dinner. —  Cold  boiled  ham,  boiled  potatoes,  pickled  beets,  canned  corn, 
bread  and  butter,  tea. 

Supper. —  Ginger  cookies,  bread  and  butter,  tea. 

Fresh  vegetables  and  fruits  in  their  season. 

Extra  diet  may  be  ordered  as  follows:  Milk  toast,  dry  toast,  egg 
on  toast,  beef  tea,  beefsteak,  chops,  ham,  scrambled  eggs,  fried  and 
boiled  eggs,  baked  custard,  cornstarch,  rice  and  milk,  gruel,  sauce, 
hot  milk,  and  chocolate.  For  each  patient  the  daily  allowance  is : 

Butter 1 J  oz. 

Sugar 1 J 

Potatoes  11§ 

Coffee   ^T 

Tea    |    ' 

Flour    Ill    ' 

Fresh  beef  10 

Fresh  vegetables  in  season  and  in  varying  amount. 

Extra  Diet 


f  Milk  toast  (for  breakfast)  \  mv.       A- 

J  **«  te     (<*™      extra<*>  /  ^  *""*  * 


Acute  mania.  , 

)  Gruel   (at  night). 


Melancholia. 


Melancholia,  re- 
fusing food  fed 
by  tube  twice 
daily. 


(about  three  quarts  daily). 
Breakfast  —  Egg  on  toast    ( no  coffee ) . 
Dinner  —  Steak  ( rare )  or  chops,  fresh  vegetables. 
Supper  —  Gruel,  sauce  (apple),  custard  or  boiled 

egg- 
Milk,  one  quart. 
Three  eggs. 
Cod-liver  oil. 
Whisky. 
Sugar. 
Salt. 

Pancreatin,  three  grains. 
Pepsin,  three  grains. 
Sodium  bicarbonate,  fifteen  grains. 


This  amount  given  twice  a  day  is  varied  once  a  week  by  chicken  or 
mutton  broth. 

"  Two  of  the  patients  fed  by  tube  with  this  combination  for  over  a 
year  remained  in  good  condition"  (Whitmore  Steele). 

In  the  Cochin  Hospital  in  Paris  there  are  8  classes  of  diet  as  follows : 

The  diet  for  healthy  persons,  for  convalescents,  for  dyspeptics,  for 
the  tuberculous  and  for  diabetics,  the  milk-vegetable  diet,  the  exclu- 
sive milk  diet  and  the  salt-free  diet. 


878 


DIETARIES,   RATIONS 


DIETARY  FOR  LIVERPOOL  INFIRMARY 
Sample  Diet  suggested  for  the  Liverpool  Infirmary  and  other  English  Hospitals 


Sick. 

Normal. 

Convalescence. 

Breakfast, 
8.30  A.  M. 

h   pt.   milk. 
3  oz.  bread  or  oatmeal 

2  pt.  of  new  milk. 
6  oz.  bread. 
2  oz.  oatmeal. 

1  pt.  new  milk. 
8   oz.   bread. 
3  oz.  oatmeal. 

Dinner, 
1.30  P.  M. 


Supper, 

6.30  to  7  P.  M. 

Bed  at  8  P.  M. 


If  cocoa  or  coffee  is  given  with  sugar,  omit  the  oatmeal  and 
give  1  pt.  of  milk. 


|    pt.   of   milk,    made 


into    pudding    with 
rice,  sago,  etc. 

J   pt.  beef  tea. 

4  oz.  bread. 


Meat,  4  oz.    (men). 


Meat,  4  oz. 
"       3  oz. 
Bread,  8  oz. 
Potato,  8  oz 
Cheese,  1  oz. 


3   oz.    (women). 
Bread,    6    oz. 
Potato.  8  oz. 
Cheese,  J  oz. 

Same  for  all  as  the  breakfast,  but  with  addition  of  a  cereal. 
|  pt.  broth  with  boiled 

meat. 

Salt  ad  libitum. 
Malt  liquor  as  exceptional  treat. 

Total  bread,  18  oz.      Total    bread,    24 
oz. 


Full  Dietaries  for  Children  at  Various  English  Hospitals    (Chambers) 


Age. 

Bread. 

Butter. 

Milk. 

Meat. 

Vegeta- 
bles. 

Pudding? 

Hospital. 

Under  7. 

Un- 

1 OZ. 

Jpt. 

2oz. 

4  oz. 

Unlimited. 

St.  George's. 

limited. 

Under  7. 

12  oz. 

? 

Ipt. 

2oz. 

Soz. 

Twice 

London. 

a  week. 

Under  8. 

5|  oz. 

About 

Jpt. 

2oz. 

4oz. 

4  pint. 

Children's     Hospi- 

§oz. 

tal,     Great     Or- 

mond  Street,  and 

Evelina      Hospi- 

tals. 

Under  8. 

8  oz. 

About 

? 

2  oz. 

4  oz. 

Leed's  Infirmary. 

1  oz. 

Above  8. 

Soz. 

About 

|pt. 

3oz. 

6oz. 

Gruel, 

Children's,    Great 

loz. 

broth. 

S  pint. 

Ormond    Street 

Ipt. 

and  Evelina  Hos- 

pitals. 

Under  9. 

Goz. 

V 

Ipt. 

2  oz. 

Coz. 

i  pint  gruel 

Birmingham     Gen- 

or broth. 

eral  Hospital. 

Under  9. 

7  oz. 

I  oz. 

Ipt. 

4  oz. 

4oz. 

To  order. 

St.  Bartholomew's. 

Under  10. 

12  oz. 

I  oz. 

Ipt. 

2  oz. 

4oz. 

Goz. 

St.  Thomas's. 

Under  10. 

Goz. 

1 

11  pt. 

2  eggs. 

f 

Soz. 

King's  College. 

HOSPITAL   DIETARIES 

Diet  of  Northeastern  Hospital  for  Children,  London 


879 


Milk  diet. 

Fish  Diet. 

Full  diet. 

Breakfast,  7  A.  M. 
Dinner,  12  M  

Milk,  J  pt.  ;  bread, 
2  oz.,  with  butter. 

Milk   J  pt.  •  rice  01 

Milk    or    cocoa,    \ 
pt.  ;  bread,  2J  oz., 
with  butter. 
Fish  boiled,  2J  oz.  • 

Milk  or  cocoa,  J  pt.  ; 
bread,  2J  oz.,  with 
butter. 
Roast      boiled      or 

Tea,  3.30  p.  M  
Supper,  6  P.  M.  ... 

other    milk    pud- 
ding. 

Milk,  i  pt.  ;  bread, 
2  oz.,  with  butter. 

Biscuit     (  cracker  ) 
or   slice  of  bread 
and  butter. 

potatoes,   mashed, 
3     oz.  ;     bread,     1 
oz.  ;      milk      pud- 
ding. 

Milk,  J  pt.;  bread, 
2£  oz.,  with  trea- 
cle or  butter. 

Bread,  2  oz.,  with 
butter,  or  cracker. 

minced   mutton,  or 
roast     or    minced 
beef,  2  J  oz.  ;  mashed 
potatoes,   4   oz.,   to 
alternate  with  green 
vegetables  •  bread,  1 
oz.;    milk  pudding. 
Bread,   2J   oz.,   wit"h 
butter,    treacle,    or 
drippings  ;    milk,   J 
pt. 
Bread,    2    oz.,    with 
butter,   or   cracker. 

Dietary  of  the  Kaiser  and  Kaiserin  Friedrich  Children's  Hospital, 
Berlin,  for  children  5  to  9  years  of  age.  There  are  three  diets,  I,  II, 
and  III,  affording  respectively  about  2,000,  1,800,  and  1,100  calories. 
(The  figures  in  the  columns  represent  grams.) 


I 

II. 

III. 

First   Meal 
Milk    (or  for  1  oatmeal  with  molasses  or  mar- 
malade )              .    .          

500 
100 
80 

50 

333 
50 
40 

'56 
10 
1 

333 

250 
'75 
250 

333 

50 

40 

250 
1 

333 

333 

250 
1 

333 
333 

Crackers      

Or  zwieback                        

Second  Meal 
Bread  or  crackers         

Crackers                             

Butter          

15 

Effff 

Relishes                  

30 
333 

250 

Milk         

Third  Meal 

Effff                                                                            .... 

125 
332 

Vegetable   puree      

Fourth  Meal 
Milk                          

ass 

50 

Fifth  Meal 

250 
1 
30 

Or  sausage    .                                

880 


DIETARIES,   RATIONS 


Dietary  of  the  Kaiser  and  Kaiserin  Friedrich  Children's  Hospital, 
Berlin,  for  children  10  to  14  years  of  age :  There  are  three  diets,  I, 
II,  and  III,  affording  respectively  about  3,200,  2,900,  and  1,800  calo- 
ries. (The  figures  in  the  columns  represent  grams.) 


I. 

II. 

III. 

First  Meal 
Milk  or  oatmeal  with  molasses  or  marmalade   .  . 

500 
100 

.333 
100 

500 

Second  Meal 

120 

50 

Butter             

30 

15 

1 

„&&    

30 

Milk                         

500 

333 

500 

Third  Meal 
Bouillon   broth  or  milk  soup   (porridge)    

250 

250 

333 

150 

75 

Effff 

1 

666 

333 

Potatoes            

300 

25 

Fourth  Meal 
Milk  

500 

333 

500 

Crackers    

100 

100 

Fifth  Meal 

120 

Crackers    

50 

Alilk  soup         

333 

333 

333 

Or  milk  and  

400 

333 

Ess    • 

1 

1 

Or  sausage   

30 

DIETARIES  OF  ARMY  HOSPITALS 
United  States  Army  Hospitals 

Special  Diet. —  The  medical  officer  will  select  from  this  list  ac- 
cording to  his  discretion:  Bread,  butter,  coffee,  tea,  toast  (dry), 
toast  (milk),  eggs  (boiled),  eggs  (poached),  milk,  beefsteak,  milk  por- 
ridge, ham,  beef  extract,  oatmeal  mush  and  milk,  chicken  (stewed), 
chicken  broth,  mutton  chop,  mutton  broth,  chocolate,  oysters  (stewed), 
beef  tea,  rice  (boiled),  farina  pudding,  cornstarch,  crackers  (soda  or 
cream),  potatoes  (baked),  potatoes  (mashed),  beef  essence,  macaroni 
(boiled),  canned  peaches  (stewed),  canned  apples  (stewed),  canned 
pears,  grapes,  oranges,  lemons,  apples,  watermelons,  cantaloupes,  etc. 


DIETARIES   OF   ARMY    HOSPITALS  881 

The  following  comprises  the  list  of  articles  allowed  in  the  ration  of 
the  II.  S.  A.  post  hospitals : 

BREAKFAST 

Bread    6  ounces. 

Butter  i  ounce. 

Coffee    1  pint. 

Tea    1     " 

Toast,  dry 4  ounces. 

Toast,  milk    6       " 

Eggs,    boiled     1 

Eggs,  poached 1 

Milk    12  ounces. 

Beefsteak    6       " 

Milk  porridge   1  pint. 

Ham    4  ounces. 

Beef  essence    2       " 

DINNER 

Bread    4  ounces. 

Chicken,  stewed    6       " 

Chicken  broth   1  pint. 

Mutton  chop 6  ounces. 

Mutton  broth    , 1  pint. 

Milk 12  ounces. 

Oysters,  stewed  1  gill. 

Beef  tea   12  ounces. 

Rice,  boiled   1  ounce. 

Farina  pudding    4  ounces. 

Cornstarch    pudding    4       " 

Milk  porridge   1  pint. 

Beefsteak    6  ounces. 

Potatoes,  mashed    6       " 

Beef  essence    2       " 

SUPPER 

Tea 1  pint. 

Butter   \  ounce. 

Bread    4  ounces. 

Toast,  dry   4       " 

Milk    12       " 

Eggs    1 

Milk  porridge   1  pint. 

Beef  essence 2  ounces. 

Following  is  the  dietary  issued  for  one  of  the  largest  United  States 
General  Hospitals  situated  at  the  Presidio  of  San  Francisco,  Cali- 
fornia : 


882 


DIETARIES,   RATIONS 


UNITED   STATES  ARMY  GENERAL  HOSPITAL 


BREAKFAST. 

DINNER. 

SUPPER. 

Sunday. 

Oatmeal  and  milk 

Vermicelli  soup. 

Veal  stew  or  boiled  ham. 

Ham  and  eggs. 
Bread  and  butter. 

Roast  veal,  sage  dressing,  or 
Turkey  or  chicken  and  dress- 

Apple sauce. 
Cake. 

Fruit. 

ing. 

Bread  and  butter. 

Coffee. 

Stewed    peas.     Mashed    pota- 

Tea. 

toes. 

Farina  pudding.     Fruit. 

Bread  and  butter.     Coffee. 

Monday. 

Germea  and  milk. 

Roast  beef. 

Codfish  balls  or  hash. 

Beefsteak. 

Mashed      potatoes.         String 

Bread  and  butter. 

Fried  potatoes. 

beans. 

Pickles. 

Bread  and  butter. 
Fruit. 

Tapioca  pudding. 
Bread    and    butter.     Fruit. 

Jam.  Sweet  crackers.  Prunes. 
Tea. 

Coffee. 

Coffee. 

Tuesday. 

Oatmeal  and  milk. 

Vegetable  soup. 

Fried  liver  and  bacon. 

Sausage. 

Baked  pork  and  beans. 

Corn  bread  and  sirup  or 

Fried  potatoes. 

Baked  tomatoes. 

Biscuits. 

Bread,            butter, 

Bread  pudding. 

Bread,  butter,  tea. 

coffee. 

Bread,  butter,  cocoa,  fruit. 

Fruit. 

Fruit. 

Wednesday. 

Milk  toast. 

Roast  mutton  with  dressing. 

Mutton  stew. 

Beefsteak. 

Mashed  potatoes. 

Pickles.     Sweet  crackers. 

Bread.            butter, 
coffee. 

Corn  or  fresh  vegetables. 
Chocolate  pudding.     Fruit. 

Bread,  butter,  tea. 
Peach  cobbler. 

Fruit. 

Bread,  butter,  coffee. 

Thu  rsday. 

Germea  and  milk. 
Hash. 

Oyster  soup. 
Corned  beef  and  cabbage. 

Sliced  roast  beef. 
Macaroni  and  cheese. 

Bread,            butter, 

Boiled  potatoes.     Radishes. 

Preserves. 

coffee. 

Rice  pudding.     Fruit. 

Bread  and  butter. 

Fruit. 

Bread,  butter,  coffee. 

Tea. 

Friday. 

Oatmeal  and  milk. 

Baked   fish  with  sauce. 

Salmon  salad.     Potato  salad. 

Bacon  and  eggs. 
Bread,            butter, 
coffee. 

Plain  boiled  potatoes. 
Fresh  salad. 
Farina  pudding.     Fruit. 

Apple  sauce. 
Ginger  crackers. 
Bread  and  butter. 

Fruit. 

Bread,  butter,  cocoa. 

Tea. 

Saturday. 

Germea  and  milk. 

Roast  beef,  veal  or  pork. 

Baked  hash  or  stew. 

Beefsteak. 

Mashed  potatoes. 

Stewed  prunes. 

Fried   potatoes. 

Hot  slaw.     Cauliflower 

Assorted  cakes. 

Bread,            butter, 

Bread   pudding. 

Bread  and  butter. 

coffee. 

Bread,  butter,   coffee. 

Tea. 

Fruit, 

DIETARIES   OF   ARMY    HOSPITALS 


883 


LIGHT  DIET 


BREAKFAST. 


DINNER. 


Sunday 

Oatmeal  and  milk.  Rice  soup. 
Soft-boiled  eggs.       Farina  pudding. 
Milk  toast.    Coft'ee.  Coffee. 


Plain  tomato  soup. 

Bread     pudding    with    lemon 

sauce. 
Coffee. 


Monday. 

Germea  and  milk. 
Milk   toast. 
Boiled  eggs. 
Coffee. 

Tuesday. 

Oatmeal  and  milk.  |  Barley  soup. 
Boiled  eggs.  Tapioca  pudding. 

Coffee.  Cocoa. 


Wednesday. 
Oatmeal  and  milk. 


Soft-boiled 
Coffee. 


eggs. 


Consomme"  vermicelli. 
Cornstarch  pudding. 
Vanilla  sauce.     Coffee. 


Thursday. 

Germea  and  milk.    Oyster  soup. 
eggs.  Rice  pudding. 


Boiled 
Coffee. 


Coffee. 


Friday. 

Oatmeal  and  milk.  Fish  chowder. 
Boiled  eggs.  .Farina  pudding. 


Milk  toast. 
Coffee. 


Cocoa. 


Saturday. 
Oatmeal  and  milk.:  Vermicelli  soup. 
Boiled  eggs.  Sago  pudding. 

Coffee. 

Coffee. 


SUPPEK. 


Milk  toast. 
Cup  custard. 
Tea. 


Farina  mush  and  milk. 
Sweet   crackers.     Jelly. 
Toast. 
Tea. 


Biscuits  or  corn  bread. 
Maple  sirup.     Boiled  rice. 
Milk  toast  and  tea. 


Sweet  crackers. 
Milk  toast. 
Tea. 


Jam. 


Macaroni  and  cheese. 
Milk  toast.     Maple  sirup. 
Tea. 


Tapioca   pudding. 

Milk  toast.    Ginger  crackers. 

Boiled  eggs. 

Tea. 


Germea  mush. 
Assorted    cakes. 
Milk  toast. 
Tea. 


Jelly. 


In  addition  to  the  regular  diet  table  a  special  diet  list  is  provided 
for  use  of  ward  surgeons  for  cases  requiring  this  class  of  diet ;  it  also 
contains  a  list  of  broths  intended  for  liquid  diets. 


DIETARIES,   RATIONS 


Ward. 


Daily  Order  List  of  Special  Diet 

U.  S.  A.  GENERAL  HOSPITAL, 
Presidio  of  San  Francisco,. ....  .1900. 


K. 


D. 


S. 


Number  of  light  diets 
Number  of  full  diets   . 

Stewed  chicken    

Chopped  beef   

Steaks    

Mutton  chops 

Baked  potatoes   

French-fried  potatoes  . 

Saratoga  chips    

Creamed  potatoes 

Baked  apples   

Wine  jelly    

Cup  custard 

Milk  toast    

Poached  eggs  

Coffee 

Tea  

BROTHS 

Beef  broth    

Mutton  broth   

Chicken  broth    

Consomme"  broth    

Oyster  broth 


Ward  Officer. 

British  Army  Hospitals 

The  following  statement  is  quoted  from  a  report  made  by  General 
Alfred  A.  Woodhull,  who  was  sent  abroad  by  the  U.  S.  Army  De- 
partment to  investigate  certain  medical  features  of  the  British  army : 

"  The  British  army  hospital  uses  seven  diets,  known  as  tea,  milk, 
beef  tea,  chicken,  convalescent,  roast,  and  varied.  Each  is  formulated 
with  exactness,  and  parts  of  two  diets  may  not  be  ordered  together. 
The  tea  diet  is:  Bread,  twelve  ounces;  tea,  half  an  ounce;  sugar, 
two  and  a  half  ounces;  milk,  six  ounces.  The  varied  diet  is:  Beef 
or  mutton,  twelve  ounces  without,  or  fifteen  ounces  with,  bone ;  bread, 
eighteen  ounces;  tea,  half  an  ounce;  sugar,  one  and  a  half  ounce; 
milk,  six  ounces;  butter,  one  ounce;  potatoes,  sixteen  ounces;  vegeta- 
bles, four  ounces,  with  salt,  pepper,  and  mustard,  and  optionally  wine, 
spirits,  malt  liquors,  and  diet  drinks  may  be  ordered.  These  diets 
represent  the  extremities  of  the  scale  through  which  the  others  run. 


DIETARIES   OF   ARMY    HOSPITALS 


885 


The  ordinary  drinks  allowed  for  patients  are:     Barley  water,  rice 
water,  gruel,  and  lemonade,  each  prepared  by  formula." 

Prussian  Army  Hospitals 

In  four  grades  of  diet  in  Prussian  military  hospitals  the  propor- 
tionate allowance  of  food  classes  is  as  follows : 


I. 

II 

III. 

IV. 

Albumin  

115 

81 

52 

18 

Fat   

55 

39 

32 

15 

Carbohydrates    

522 

315 

127 

French  Army  Hospitals 

Kirchner  gives  the  following  analysis  of  the  nutrient  ingredients 
of  the  seven  different  classes  into  which  diet  in  the  French  military 
hospitals  is  divided.  "  Absolute  diet"  (diet  absolue)  is  practical 
starvation,  at  most,  only  a  little  toast  water  being  given,  and  is  of 
temporary  service  only : 


Albumin. 

Fats. 

Carbohydrates. 

Full    diet      

Grams 
119 

Grams. 
57 

Grams. 
448 

§  diet    

91 

47 

357 

1     " 

70 

39 

225 

1     " 

35 

25 

134 

ft     " 

19 

17 

89 

Bread  diet   

14 

36 

89 

Absolute  diet                 

APPENDIX 


EECEIPTS  FOE  INVALID'S  FOOD  AND  BEVEEAGES,  SUIT- 
ABLE FOE  FEVEES  AND  CONVALESCENCE  FEOM 
ACUTE  ILLNESS 


BEVERAGES 
i.  Demulcent  and  Nutritive 

Barley  Water  (Pavy). —  Take  two  ounces  of  pearl  barley  and  wash 
well  with  cold  water,  rejecting  the  washings.  Afterwards  boil  with  a 
pint  and  a  half  of  water  for  twenty  minutes  in  a  covered  vessel,  and 
strain.  The  product  may  be  sweetened  and  flavored  with  lemon  peel, 
or  lemon  peel  may  be  introduced  while  boiling  is  carried  on.  Lemon 
juice  is  also  sometimes  added  to  flavor.  A  bland,  demulcent,  and 
mildly  nutritive  beverage. 

Barley  Water  (Bartholow). —  Wash  two  ounces  of  pearl  barley 
with  cold  water;  boil  for  five  minutes  in  fresh  water,  and  throw  both 
waters  away ;  pour  on  two  quarts  of  boiling  water,  and  boil  down  to  a 
quart.  (Stir  and  skim  occasionally.)  Flavor  with  thinly  cut  lemon 
rind;  add  sugar  to  taste,  but  do  not  strain  unless  at  the  patient's 
request. 

Barley  Water  (Ringer) . —  To  a  tablespoonf ul  of  pearl  .barley 
washed  in  cold  water  add  two  or  three  lumps  of  sugar,  the  rind  of 
one  lemon,  and  the  juice  of  half  a  lemon.  On  these  pour  a  quart 
of  boiling  water,  and  let  the  mixture  stand  for  seven  or  eight  hours. 
Strain.  The  barley  water  should  never  be  used  a  second  time.  Half 
an  ounce  of  isinglass  may  be  boiled  in  the  water.  If  not  needed  at 
once,  these  barley  preparations  should  be  kept  in  the  refrigerator  and 
warmed  when  required. 

Rice  Water  or  Mucilage  of  Rice  (Pavy). —  Thoroughly  wash  one 
ounce  of  rice  with  cold  water.  Macerate  for  three  hours  in  a  quart  of 
water  kept  at  a  tepid  heat,  and  afterwards  boil  slowly  for  an  hour, 
and  strain.  A  useful  drink  in  dysentery,  diarrhoea,  and  irritable 
states  of  the  alimentary  canal.  It  may  be  sweetened  and  flavored  in 
the  same  way  as  barley  water. 

887 


888  APPENDIX 

Demulcent  Drink  (Ringer). —  Take  a  pinch  of  isinglass,  and  boil 
it  in  half  a  pint  of  new  milk  with  half  a  dozen  bruised  sweet  almonds 
and  three  lumps  of  sugar. 

Linseed  Tea  (Chambers). —  Whole  linseed,  white  sugar,  each  one 
ounce;  licorice  root,  one  half  ounce;  lemon  juice,  two  ounces.  Mix. 
An  agreeable  dumulcent. 

Flaxseed  Tea. —  One-half  cupful  of  flaxseed  to  one  quart  of  boil- 
ing water;  boil  thirty  minutes  and  let  stand  a  little  while  near  the 
fire  to  thicken  more.  Strain,  and  add  lemon  juice  and  sugar. 

Currant  Jelly  (Fagge). —  Red  or  black  currant  jelly,  dissolved  in 
hot  or  cold  water,  or  strained  tamarind  tea,  make  excellent  invalid 
beverages. 

2.  Diuretic  and  Refrigerant 

Lemonade  (Pavy). —  Pare  the  rind  from  a  lemon  thinly,  and  cut 
the  lemon  into  slices.  Put  the  peel  and  sliced  lemon  into  a  pitcher 
with  one  ounce  of  white  sugar,  and  pour  over  them  one  pint  of  boiling 
water.  Cover  the  pitcher  closely,  and  let  stand  until  cold.  Strain  or 
pour  off  the  liquid.  Citron  may  be  used,  instead  of  lemon,  and  like- 
wise furnishes  a  soothing  and  refrigerant  beverage. 

Lemonade,  Effervescing  (Ringer). —  To  the  expressed  juice  of  a 
large  lemon  add  a  lump  or  two  of  sugar  previously  lightly  rubbed 
on  the  rind.  Pour  on  it  half  a  pint  of  cold  or  iced  water.  To  cause 
it  to  effervesce  put  it  into  a  large  tumbler  and  add  half  a  teaspoonful 
of  bicarbonate  of  soda  or  potash.  Stir  and  drink  while  effervescing. 
A  very  agreeable  and  refreshing  beverage. 

Lemonade  (Ringer). —  Pare  the  rind  of  three  lemons  as  thin  as 
possible,  add  one  quart  of  boiling  water  and  a  quarter  of  an  ounce 
of  isinglass.  Let  them  stand  till  next  day  covered;  then  squeeze  the 
juice  of  eight  lemons  upon  half  a  pound  of  lump  sugar;  when  the 
sugar  is  dissolved,  pour  the  lemon  and  water  upon  them,  mix  all  well 
together,  strain,  and  it  is  ready  for  use. 

Orangeade  ( U.  S.  Army  Hospitals) . —  One  orange.  One  teaspoon- 
ful of  sugar.  Three-fourths  of  a  coffee  cup  of  water  (six  ounces). 
Wash  and  wipe  the  orange.  Squeeze  the  juice  into  the  sugar.  Add  the 
cold  water,  previously  boiled.  Strain  and  serve. 

Cream-of-tartar  Drink. —  Potus  Imperialis. —  Imperial  Drink 
(Pavy). —  Dissolve  a  drachm  or  a  drachm  and  a  half  of  cream  of 
tartar  in  a  pint  of  boiling  water,  and  flavor  with  lemon  peel  and  sugar. 
When  cold,  strain  and  take  ad  libitum  as  a  refrigerant  drink  and 
diuretic. 

Cream-of-tartar  Whey    (Pary). —  Stir  a  quarter  of  an  ounce  of 


BEVERAGES  889 

cream  of  tartar  (a  large  teaspoonful  piled  up)  into  a  pint  of  boiling 
milk,  and  strain.  A  refrigerant  and  diuretic  drink,  which  is  rendered 
more  agreeable  by  the  addition  of  sugar. 

Raspberry  Vinegar  (Maria  Parloa). —  Put  four  quarts  of  rasp- 
berries in  a  bowl  and  pour  over  them  2  quarts  of  vinegar.  Cover 
and  set  in  a  cool  place  for  two  days.  On  the  second  day  strain  the 
vinegar  through  cheese  cloth.  Put  4  quarts  of  fresh  raspberries  in 
the  bowl  and  pour  over  them  the  vinegar  strained  from  the  first  rasp- 
berries. Put  in  a  cool  place  for  two  days,  then  strain.  Put  the 
strained  juice  in  a  preserving  kettle  with  3  quarts  of  sugar.  Heat 
slowly,  and  when  the  vinegar  boils  skim  carefully.  Boil  twenty  min- 
utes, then  put  in  sterilized  bottles. 

About  2  tablespoonfuls  of  vinegar  to  a  glass  of  water  makes  a 
refreshing  drink. 

Similar  vinegars  may  be  made  from  blackberries  and  strawberries. 

White  Wine  Whey  or  Posset  (Pavy).—  To  half  a  pint  of  milk 
while  boiling  in  a  saucepan  add  one  wineglassful  of  sherry  or  white 
wine  and  afterwards  strain  through  a  muslin  cloth.  Sweeten  with 
pounded  sugar  according  to  taste.  A  useful  diuretic  drink  in  colds 
and  mild  febrile  disorders.  For  a  child,  give  a  tablespoonful  every 
two  hours. 

Wine  Whey. —  Milk,  one  pint;  wine  of  pepsin,  one  teaspoonful. 
Heat  gently  to  115°  or  120°  F.,  let  stand,  break  the  curd,  strain,  and 
add  sherry  in  the  proportion  of  1  to  8  or  10.  Drink  cold. 

Tamarind  Whey  (Pavy). —  Stir  two  tablespoonfuls  of  tamarinds 
into  a  pint  of  milk  while  boiling,  and  afterwards  strain.  This  forms 
a  refrigerant  and  slightly  laxative  drink. 

Mulled  Wine  (Ringer). —  Boil  some  spice,  cloves,  nutmeg,  cinna- 
mon, or  mace  in  a  little  water  to  flavor  the  wine ;  add  a  wineglassful 
of  sherry,  port  or  other  wine  and  some  sugar;  bring  it  to  the  boiling 
point,  and  serve  with  sippets  of  toast.  If  claret  is  used,  it  will  re- 
quire more  sugar. 

3.  Milk  Beverages 

Koumiss,  kephir,  matzoon,  malted  milk,  whey,  skimmed  milk,  but- 
termilk, milk  diluted  with  equal  parts  of  Vichy,  carbonic  water,  or 
lime  water ;  milk  flavored  with  coffee,  caramel,  vanilla,  or  spice ;  cream 
diluted  with  water  or  Vichy  to  the  consistency  of  milk. 

FLUID  BEEF  PREPARATIONS 

Beef  Juice  (Bartholow). —  Broil  quickly  some  pieces  of  round  or 
sirloin  of  a  size  to  fit  in  the  cavity  of  a  lemon  squeezer  previously 


890  APPENDIX 

heated  by  being  dipped  in  hot  water.  The  juice,  as  it  flows  away, 
should  be  received  into  a  hot  wineglass,  and,  after  being  seasoned  to 
the  taste  with  salt  and  a  little  Cayenne  pepper,  taken  while  hot. 

Beef  Essence  (Yeo). —  Cut  the  lean  of  beef  into  small  pieces  and 
place  them  in  a  wide-mouthed*  bottle  securely  corked,  and  then  allow 
it  to  stand  for  several  hours  in  a  vessel  of  boiling  water.  This  may 
be  given  to  infants,  who  cannot  take  milk,  in  teaspoonful  doses,  and 
in  larger  quantities  to  adults. 

Beef  Tea  (Pavy) . —  Put  a  pound  of  finely  minced  beef  into  a  suit- 
able vessel  with  a  pint  of  cold  water.  Let  it  stand  for  an  hour,  stir- 
ring occasionally.  Place  the  vessel  containing  the  beef  into  a  sauce- 
pan of  water,  place  over  the  fire,  and  allow  the  water  to  boil  gently 
for  an  hour  (or  the  vessel  containing  the  beef  tea  may  be  put  into  an 
ordinary  oven  for  an  hour).  Pass  the  beef  tea  through  a  strainer. 
It  contains  a  quantity  of  fine  sediment,  which  should  be  drunk  with 
the  liquid.  Flavor  with  salt.  In  this  process  the  beef  extract  should 
not  be  exposed  to  a  temperature  of  more  than  170°  F. 

Beef  Tea  (Bryce). —  Lean  beef,  chopped  fine,  free  from  fiber,  one 
pound ;  water,  one  pint ;  sodium  bicarbonate,  ten  grains ;  simmer  half 
an  hour  in  a  glass-covered  preserve  jar,  decant  the  fluid,  squeeze  the 
meat  to  a  pulp  in  a  lemon  squeezer,  return  both  to  jar,  add  extract  of 
pancreas,  cover,  keep  at  140°  F.  for  twelve  hours,  shaking  occasionally. 
When  an  acid  taste  appears,  boil  two  or  three  minutes  to  stop  further 
fermentation. 

This  tea,  it  is  claimed,  equals  the  same  bulk  of  peptonized  milk  in 
nutrient  value. 

Chrystie's  Beef  Tea. —  Macerate  for  one  hour  one  pound  of  finely 
minced  lean  beef  in  a  pint  of  water,  containing  fifteen  grains  of 
sodium  chloride  and  five  drops  of  dilute  hydrochloric  acid,  at  100°  F. 

Filter  through  cheese  cloth,  and  wash  the  residue  with  half  a  pint 
of  fresh  water.  The  filtrate  is  transparent,  has  a  not  unpleasant  taste, 
and  contains  a  considerable  amount  of  albuminoids.  A  child  of  two 
years  may  take  two  or  three  ounces  daily. 

Beef  Tea  (Bartholow). —  Chop  fine  a  pound  of  lean  beef  free  from 
fat,  tendons,  etc.,  and  digest  with  a  pint  of  cold  water  for  two  hours. 
Let  it  simmer  on  the  stove  for  three  hours,  at  a  temperature  never 
over  100°  F.  Make  up  the  water  lost  in  evaporation  by  adding  cold 
water,  so  that  a  pint  of  beef  tea  shall  represent  a  pound  of  beef. 
Strain,  and  carefully  express  all  fluid  from  the  beef. 

Beef  Tea  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men). —  Beef, 
twelve  pounds :  salt,  one  ounce. 

The  beef  should  be  lean  and  juicy,  and  cut  into  small  pieces.     Put 


BROTHS  AXD   SOUPS  891 

it  into  one  gallon  and  a  half  of  cold  water  with  the  salt.  Let  it  boil 
gently  for  three  hours.  If  it  should  boil  away  too  fast,  add  the  req- 
uisite quantity  of  boiling  water  and  let  it  boil  fifteen  minutes  longer. 
When  done  it  should  measure  twelve  pints.  Set  it  aside  to  cool. 
Eemove  every  particle  of  grease,  and  heat  when  required.  In  case  of 
a  deficiency  of  fresh  beef,  use  the  beef  extract  supplied  in  the  hospital 
stores. 

Beef  Extract  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men).— 
Infuse  a  third  of  a  pound  of  fresh  beef,  finely  minced,  in  fourteen 
ounces  of  cold  soft  water,  to  which  a  few  drops  (four  or  five)  of 
muriatic  acid  and  a  little  salt  (from  ten  to  eighteen  grains)  have 
been  added.  After  digesting  for  an  hour  to  an  hour  and  a  quarter, 
strain  it  through  a  sieve  and  wash  the  residue  with  five  ounces  of  cold 
water,  pressing  it  to  remove  all  soluble  matter.  The  mixed  liquid 
will  contain  the  whole  of  the  soluble  constituents  of  the  meat  (albu- 
min, creatin,  etc.),  and  it  may  be  drank  cold  or  slightly  warmed.  The 
temperature  should  not  be  raised  above  100°  F.,  as  at  the  temperature 
of  113°  F.  a  considerable  portion  of  the  albumin,  a  very  important 
constituent,  will  be  coagulated. 

Meat  Extract  (Rosenthal  and  Leube). —  One  thousand  grams  ojf 
lean  meat,  minced  fine,  are  placed  in  a  porcelain  vessel  with  one 
thousand  grams  of  water,  and  twenty  centigrams  of  dilute  hydro- 
chloric acid.  This  is  placed  in  a  closed  Papin's  digester  and  boiled 
for  ten  to  fifteen  hours.  The  mass  is  then  taken  out  and  rubbed 
in  a  mortar  to  a  paste.  It  is  again  boiled  in  the  closed  digester  for 
another  sixteen  to  twenty  hours;  after  this  it  is  neutralized  with 
pure  sodium  carbonate,  and  evaporated  to  a  sirupy  consistence. 

Restorative  Beef  Essence  (Ringer). —  Take  one  ounce  of  fresh 
beef,  free  from  fat,  chop  fine,  and  pour  over  it  eight  ounces  of  soft 
water,  add  five  or  six  drops  of  dilute  hydrochloric  acid,  and  fifty 
or  sixty  grains  of  common  salt,  stir  well,  and  leave  for  three  hours 
in  a  cool  place.  Then  pass  the  fluid  through  a  hair  sieve,  pressing 
the  meat  slightly,  and  adding  gradually  toward  the  end  of  the  strain- 
ing about  two  more  ounces  of  water.  The  liquid  thus  obtained  is  of  a 
red  color,  possessing  the  taste  of  soup.  It  should  be  taken  cold,  a 
teaspoonful  at  a  time.  If  preferred  warm,  it  must  not  be  put  on  the 
fire,  but  heated  in  a  covered  vessel  placed  in  hot  water. 

BROTHS  AND  SOUPS 

Chicken  Broth  (BartlioJow). —  Skin  and  chop  up  fine  a  small 
chicken  or- half  a  large  fowl,  and  boil  it,  bones  and  all,  with  a  blade 


892  APPENDIX 

of  mace,  a  sprig  of  parsley,  and  a  crust  of  bread,  in  a  quart  of  water 
for  an  hour,  skimming  it  from  time  to  time.  Strain  through  a  coarse 
colander. 

Chicken,  Veal,  or  Mutton  Broth  (Yeo). —  Chicken,  veal,  or  mutton 
broth  may  be  made  like  beef  tea,  substituting  chicken,  veal,  or  mut- 
ton for  beef,  boiling  in  a  saucepan  for  two  hours,  and  straining. 
For  chicken  broth  the  bones  should  be  crushed  and  added.  For 
veal  broth  the  fleshy  part  of  the  knuckle  should  be  used.  Either 
may  be  thickened  and  their  nutritive  value  increased  by  the  addition 
of  pearl  barley,  rice,  vermicelli,  or  semolina. 

Mutton  and  Chicken  Broths  (Osier). —  Mince  a  pound  of  either 
chicken  or  mutton,  freed  from  fat,  put  into  a  pint  of  cold  water,  and 
let  stand  in  a  cold  jar  on  ice  two  to  three  hours.  Then  cook  three 
hours  over  a  slow  fire,  strain,  cool,  skim  off  fat,  add  salt,  and  serve 
hot  or  cold.  Such  broth  is  much  better  than  any  manufactured  meat 
preparations.  Good  mutton  broth  is  difficult  to  make  on  account  of 
the  meat  containing  so  much  fat. 

Chicken  Broth  (U.  8.  Army  Hospital  Receipt  for  Twelve  Men). — 
Chicken,  one ;  salt,  two  ounces ;  flour,  two  ounces. 

Cut  the  chicken  into  pieces.  Put  it  with  the  salt  into  the  kettle 
with  twelve  pints  of  cold  water.  Let  it  simmer  gently  two  or  three 
hours,  carefully  and  frequently  skimming  off  the  grease.  Make  a 
paste  of  the  flour  with  some  cold  water;  stir  it  in  and  boil  ten 
minutes  longer.  It  should  measure  ten  pints  when  done. 

Mutton  Broth  (U.  8.  Army  Hospital  Receipt  for  Twelve  Men). — 
Mutton,  six  pounds;  salt,  two  ounces;  rice,  two  ounces. 

Break  the  bones  without  separating  the  meat.  Put  it  into  twelve 
pints  of  cold  water,  with  the  salt  and  rice  or  barley.  Boil  gently 
two  hours  and  a  half,  carefully  removing  all  the  scum  and  fat.  If 
the  broth  should  boil  away  too  much,  add  the  requisite  quantity  of 
boiling  water  to  make  twelve  pints,  and  let  it  boil  fifteen  minutes 
longer. 

Invalid  Broths. —  To  one  pound  of  chopped  lean  meat,  either 
chicken,  mutton,  or  beef,  add  one  pint  of  cold  water  (or  one  pint 
and  a  half  on  ice  for  a  young  infant),  let  stand  in  a  covered  glass 
fruit  jar  for  four  to  six  hours,  cook  for  three  hours  in  a  closed  jar 
over  a  slow  fire,  strain,  cool,  skim  off  the  fat,  clear  with  egg,  season, 
and  feed  warm  or  cold. 

Bouillon  (Broth)  as  TJsed  in  the  Hospitals  of  Paris  (Yeo). —  Eaw 
meat,  without  bone,  one  kilogram;  fresh  vegetables,  four  hundred 
grams  (about  one  pound)  ;  salt,  ten  grams  (about  one  hundred  and 
fifty  grains).  Boil  very  slowly  over  a  gentle  fire. 


SOLID   MEAT  PREPARATIONS  893 

Nourishing  Soup  (Ringer}. —  Stew  two  ounces  of  the  best  well- 
washed  sago  in  a  pint  of  water  till  it  is  quite  tender  and  very  thick; 
then  mix  it  with  half  a  pint  of  good  boiling  cream  and  the  yolks  of 
two  fresh  eggs.  Blend  the  whole  carefully  with  one  quart  of  essence 
of  beef.  The  beef  essence  should  be  heated  separately,  and  mixed 
while  both  mixtures  are  hot.  A  little  of  this  may  be  warmed  at  a 
time. 

Consomme'. —  Consomme  may  be  flavored  with  vegetable  extracts 
or  expressed  juice  of  vegetables  boiled  in  it.  Thicken  soups  with 
arrowroot,  ground  rice,  or  cornflour. 

Beef  Tea  with  Oatmeal  (Anderson). —  This  forms  a  very  nutritious 
food.  Take  two  tablespoonfuls  of  oatmeal  and  two  of  cold  water 
and  mix  them  thoroughly;  then  add  a  pint  of  good  beef  tea  which 
has  just  been  brought  to  the  boiling  point.  Boil  together  for  five 
minutes,  stirring  it  well  all  the  time,  and  strain  through  a  hair 
sieve. 

SOLID  MEAT  PREPARATIONS 

Eaw-meat  Diet  (Ringer). —  From  two  ounces  of  rump  steak  take 
away  all  fat,  cut  into  small  squares  without  entirely  separating  the 
meat,  place  in  a  mortar,  and  pound  for  five  or  ten  minutes;  add 
three  or  four  tablespoonfuls  of  water  and  pound  again  for  a  short 
time,  afterwards  removing  all  sinew  or  fiber;  add  salt  to  taste.  Be- 
fore using,  place  the  cup  or  jar  containing  the  pounded  meat  in 
hot  water  until  warm. 

Or  scrape  the  beefsteak  with  a  sharp  knife  and,  after  removing 
all  fat  and  tendon,  if  not  already  in  a  complete  pulp,  pound  in  a 
mortar.  Flavor  with  salt  and  pepper.  This  may  be  taken  in  the 
form  of  a  sandwich  between  thin  bread  and  butter  or  mixed  with 
water  to  the  consistence  of  cream.  If  preferred,  the  meat  may  be 
rolled  into  balls  with  a  little  white  of  egg  and  broiled  for  two  min- 
utes, or  until  the  outside  turns  gray  —  just  long  enough  to  remove 
the  raw  taste. 

This  diet  is  excellent  for  children  with  diarrhoea,  also  for  adults 
who  suffer  from  irritable  bowels  or  chronic  diarrhoea. 

Scraped  Beef  (U.  8.  Army  Hospitals). —  Cut  a  piece  of  steak  from 
the  round,  about  half  a  pound  in  weight  and  about  an  inch  thick. 
Lay  it  on  a  clean  meat  board  and  with  a  dull  knife  scrape  out  the 
pulp  until  there  is  nothing  left  but  stringy  fiber.  Season  the  scraped 
pulp  with  salt  and  make  it  into  small  cakes.  Broil  for  two  minutei 
either  by  direct  heat  over  a  clear  fire,  or  by  heating  a  clean  pan  or 
plate  and,  when  hot,  placing  the  meat  on  it.  Have  both  sides  cooked 


894  APPENDIX 

sufficiently.  This  is  a  safe  food  for  a  patient  beginning  to  take 
solid  nourishment.  Scraped  beef  may  be  prepared  very  easily  over 
an  alcohol  lamp. 

Scraped-beef  Sandwiches  ( U.  8.  Army  Hospitals) . —  Place  a  piece 
of  round  steak  on  a  meat  board  and  scrape  out  all  of  the  pulp  with 
a  dull  knife;  add  to  the  pulp  a  little  salt  and  pepper  and  enough 
raw  beef  juice  to  make  it  into  a  firm  jelly.  Have  stale  bread  cut 
into  very  thin  slices  and  spread  the  beef  pulp  on  them;  cut  the 
sandwiches  quite  small.  Never  use  butter  in  making  beef  sand- 
wiches. 

Meat  Biscuits  (ParJces) . —  Mix  together,  cook,  and  bake  one  pound 
of  flour,  one  pound  of  meat,  one-quarter  of  a  pound  of  suet,  one-half 
pound  potatoes  with  a  little  sugar,  onion,  salt,  pepper,  and  spices. 
A  palatable  meat  biscuit,  weighing  about  one  pound  and  a  quarter, 
containing  10  to  12  per  cent  of  water,  is  thus  obtained  which  keeps 
quite  unchanged  for  four  months. 

Raw-meat  Sandwiches  (from  "Food"). —  Three  ounces  of  raw 
beef  or  mutton,  one  ounce  of  very  fine  bread  crumbs,  one  teaspoonful 
of  sugar;  cut  the  meat  very  fine,  rub  it  through  a  hair  sieve,  then 
pound  it  in  a  mortar  into  a  paste.  Mix  with  it  the  bread  crumbs, 
sugar,  a  little  salt  and  pepper ;  spread  it  between  thin  slices  of  either 
brown  or  white  bread  and  butter. 

Chicken  Jelly  (Adams). —  Clean  a  fowl  that  is  about  a  year  old, 
remove  skin  and  fat;  chop  fine,  bones  and  flesh,  place  in  pan  with 
two  quarts  of  water;  heat  slowly;  skim  thoroughly;  simmer  five  to 
six  hours;  add  salt,  mace,  or  parsley  to  taste,  strain;  cool.  When 
cool,  skim  off  the  fat. 

The  jelly  is  usually  relished  cold,  but  may  be  heated.  Give  often 
in  small  quantities. 

Enema  of  Meat  and  Pancreas  (Leube}. —  Mince  from  one  hundred 
and  fifty  to  three  hundred  grams  of  meat,  and  mix  with  fifty  to 
one  hundred  grams  of  finely  chopped  pancreas,  free  from  fat.  Beat 
the  mixture  into  a  paste  with  a  pestle  or  spoon,  adding  a  little 
lukewarm  water  to  make  it  of  a  suitable  consistence  for  injection 
through  the  enema  tube.  Use  warm;  if  cold  it  may  excite  the  rec- 
tum  and  cause  expulsion.  If  thought  desirable,  from  twenty-five  to 
fifty  grams  of  fat  may  be  mixed  intimately  with  the  mass  by  the 
help  of  a  warm  pestle.  A  syringe  with  a  wide  nozzle  must  be  used. 

MILK  PREPARATIONS 

Milk-and-cinnamon  Drink  (Ringer}. —  Boil  in  one  pint  of  new  milk 
sufficient  cinnamon  to  flavor  it  pleasantly,  and  sweeten  with  white 


MILK  PREPARATIONS  895 

sugar.  This  may  be  taken  cold  with  a  teaspoonful  of  brandy,  and 
is  very  good  in  cases  of  diarrhrea.  Children  may  take  it  warm  with- 
out brandy. 

Albuminized  Milk  (U.  S.  Army  Hospitals). —  Beat  up  the  white  of 
an  egg  till  light.  Add  a  good-sized  pinch  of  salt,  and  four  ounces 
of  fresh,  cool  milk  which  has  been  sterilized.  A  little  sugar  may  be 
added  if  desired. 

Milk  Punch. —  Make  by  adding  brandy  or  whisky  or  rum  to  milk 
in  the  proportion  of  about  one  to  four  or  six  parts  of  milk;  flavor 
with  sugar  and  nutmeg;  shake  well. 

Sherry  or  Brandy  and  Milk  (Ringer) . —  To  one  tablespoonful  of 
brandy  or  one  wineglassful  of  sherry,  in  a  bowl  or  cup,  add  pow- 
dered sugar  and  a  very  little  nutmeg  to  taste.  Warm  a  breakfast- 
cupful  of  new  milk  and  pour  into  a  pitcher.  Pour  the  contents  from 
a  height  over  the  wine,  sugar,  etc.  The  milk  must  not  boil. 

Rum  and  Milk  (Fothergill) .—  Half  a  pint  of  new  milk,  one  egg. 
one  to  two  teaspoonfuls  of  powdered  sugar,  grated  nutmeg,  one  to 
two  teaspoonfuls  of  good  old  Jamaica  rum.  Mix. 

Junket  (Anderson). —  Sweeten  with  white  sugar  one  pint  of  good 
milk.  If  wine  is  allowed,  a  dessertspoonful  of  sherry  is  an  improve- 
ment. Heat  to  new  milk  warmth,  pour  into  a  shallow  dish,  and  stir 
in  two  teaspoonfuls  of  essence  of  rennet.  This  will  form  a  slight 
curd.  Grate  a  little  nutmeg  over  it  or  add  a  pinch  of  powdered 
cinnamon.  Serve  when  quite  cold.  In  cold  weather  the  milk  should 
be  placed  in  a  warm  room  to  set.  An  excellent  food,  and  good  sub- 
stitute for  milk  in  typhoid  fever,  etc. 

Artificial  Human  Milk  (FranJcland) . —  Allow  one-third  of  a  pint 
of  new  milk  to  stand  twelve  hours,  remove  the  cream,  and.  mix  it 
with  two-thirds  of  a  pint  of  perfectly  fresh  cow's  milk.  Take  the 
milk  from  which  the  cream  was  removed  and  put  a  piece  of  rennet 
about  an  inch  square  (fluid  rennet  may  be  employed)  into  it.  Keep 
the  vessel  containing  it  in  a  warm  place  until  the  milk  is  fully 
curdled,  an  operation  requiring  five  to  fifteen  minutes,  according 
to  the  activity  of  the  rennet,  which  should  be  removed  as  soon 
as  the  curdling  commences,  and  put  into  an  eggcup  for  use  on 
subsequent  occasions,  as  it  may  be  employed  daily  for  a  month  or 
two.  Break  up  the  curd  repeatedly,  and  carefully  separate  the  whole 
of  the  whey,  which  should  then  be  heated  rapidly  to  boiling  in  a 
small  tin  pan,  placed  over  a  spirit  or  gas  lamp.  During  the  heating 
a  further  quantity  of  casein  [albumin?],  technically  called  "fleet- 
ings,"  separates,  and  must  be  removed  by  straining  tli rough  clean 
muslin.  Xow  dissolve  one  hundred  and  ten  grains  of  powdered 


896  APPENDIX 

sugar  of  milk  in  the  hot  whey,  and  mix  it  with  two-thirds  of  a  pint 
of  new  milk  to  which  the  cream  from  the  other  fluid  has  been 
added,  as  already  described.  The  artificial  milk  should  be  used 
within  twelve  hours  of  its  preparation. 

Biedert's  Cream  Mixture. —  Mix  four  ounces  of  cream  with  twelve 
ounces  of  warm  water  and  add  one-half  ounce  of  milk  sugar. 

Koumiss  (Anderson). —  To  one  pint  of  new  milk  add  three  ounces 
of  water,  three  ounces  of  old  koumiss  (for  a  ferment),  and  one  ounce 
of  saturated  solution  of  sugar  of  milk.  Put  all  in  a  large  jug,  cover 
carefully,  and  set  the  jug  in  a  warm  place  for  twenty-four  hours. 
By  that  time  a  thick  crust  will  have  formed  on  the  surface  of  the 
mixture;  beat  this  up  thoroughly  and  mix  all  well.  Then  put  the 
whole  into  champagne  bottles,  which  should  be  no  more  than  two- 
thirds  full,  and  cork  and  wire.  Shake  the  bottles  daily.  The  kou- 
miss will  be  fit  for  use  in  two  days,  but  it  is  much  improved  by 
keeping  for  about  six  weeks.  It  should  be  drawn  off  with  a  tap. 

Home-made  Koumiss. —  Boil  fresh  milk,  and  when  nearly  cold  put 
into  quart  bottles,  leaving  room  to  shake.  Add  half  an  ounce  of 
crushed  lump  sugar  and  a  piece  of  Vienna  yeast  the  size  of  a  hazel 
nut  (i.  e.,  twenty  grains),  cork  with  new  corks,  tie  down,  keep 
cool,  lay  the  bottles  horizontal,  but  shake  twice  daily.  Eeady  to 
drink  on  the  sixth  day,  or  earlier  in  hot,  later  in  cold  weather. 

The  koumiss  may  be  made  thinner  by  using  skimmed  milk. 

Home-made  Lime  Water. —  Pour  two  quarts  of  hot  water  over 
fresh,  unslacked  lime  (size  of  a  walnut),  stir  till  slacked,  let  stand 
till  clear  and  bottle.  Often  ordered  with  milk  to  neutralize  acidity 
of  the  stomach. 

Savory  and  Moore  prepare  a  concentrated  predigested  milk  and  milk 
with  cocoa,  which  have  an  agreeable  taste  and  considerable  nutrient 
value.  Another  preparation  is  Loeflund's  Peptonized  Kindermilch. 

One  or  two  drachms  of  Benger's  Liquor  Pancreaticus  with  fifteen 
grains  of  sodium  bicarbonate  will  completely  peptonize  half  a  pint  of 
milk  in  a  few  minutes  if  the  bottle  be  immersed  in  water  which  is 
heated,  but  which  is  not  too  hot  for  the  hand  to  bear.  Eoberts's  rule 
for  pancreatinized  milk  gruel  is  quoted  by  Yeo  as  follows :  "  A  good 
thick  gruel  made  with  oatmeal  or  other  meal  while  still  boiling  hot 
is  added  to  an  equal  quantity  of  cold  milk.  The  temperature  of  the 
mixture  will  then  be  about  140°  F.  To  a  pint  of  this  mixture  two 
or  three  teaspoonfuls  of  Liquor  Pancreaticus  and  twenty  grains  of 
bicarbonate  of  soda  are  added:  it  is  kept  at  the  same  temperature 
for  about  two  or  three  hours,  and  then  boiled  for  a  few  minutes  and 
strained.  This  mixture  contains  not  only  the  casein  of  the  milk 


EGG  PREPARATIONS  897 

peptonized,  but  the  starch  of  the  material  is  converted  into  sugar 
and  its  albuminates  are  peptonized.  The  bitterness  of  the  pepton- 
ized  milk  is  scarcely  perceptible  in  this  gruel." 


EGG  PREPARATIONS 

Eggnog. —  Eggnog  is  made  by  adding  the  beaten  yolk  of  an  egg  and 
a  little  spirits  to  a  tumblerful  of  milk,  stirring  well,  adding  sugar  and 
the  white  of  the  egg,  separately  beaten.  The  digestibility  of  both  of 
these  highly  nourishing  and  stimulating  preparations  is  enhanced  by 
the  addition  of  half  an  ounce  of  lime  water,  which  does  not  affect 
the  taste. 

Egg  and  Wine  (Ringer). —  Take  one  egg,  half  a  glass  of  cold 
water,  one  glass  of  sherry,  sugar,  and  a  very  little  nutmeg  grated. 

Beat  the  egg  to  a  froth  with  a  tablespoonful  of  cold  water.  Make 
the  wine  and  water  hot,  but  not  boiling;  pour  on  the  egg,  stirring 
all  the  time.  Add  sufficient  sugar  to  sweeten,  and  a  very  little  nut- 
meg. Put  all  into  a  porcelain-lined  saucepan  over  a  gentle  fire  and 
stir  one  way  till  it  thickens,  but  do  not  let  it  boil.  Serve  in  a  glass 
with  crisp  biscuits  or  sippets  of  toast. 

Eggnog  (Bartholow). —  Scald  some  new  milk  by  putting  it,  con- 
tained in  a  jug,  into  a  saucepan  of  boiling  water,  but  it  must  not  be 
allowed  to  boil.  When  quite  cold  beat  up  an  egg  with  a  fork  in  a 
tumbler  with  some  sugar;  beat  quite  to  a  froth;  add  a  dessertspoon- 
ful of  brandy  and  fill  up  the  tumbler  with  scalded  milk.  A  nutritive 
drink  in  acute  disease. 

Brandy  and  Egg  Mixture  (British  Pharmacopoeia). —  Eub  together 
the  yolks  of  two  eggs  and  half  an  ounce  of  refined  sugar,  and  add 
four  ounces  of  Cognac  and  four  ounces  of  cinnamon  water.  A  more 
generally  useful  mixture  may  be  made  with  half  this  quantity  of 
brandy. 

Stokes's  Cognac  Mixture. —  Best  Cognac,  distilled  water,  each  fif- 
teen ounces ;  yolk  of  one  egg ;  sirup,  six  ounces.  Mix.  Give  a  table- 
spoonful  every  two  or  three  hours. 

Egg  and  Brandy  Mixture  (Anderson). —  Beat  up  three  eggs  to  a 
froth  in  four  ounces  of  cold  water  and  then  add  four  ounces  of  brandy. 
Mix  well  and  sweeten  to  taste.  A  little  nutmeg  may  be  added.  Give 
a  tablespoonful  or  so  at  a  time. 

Lemonade  with  Eggs  (Einger). —  The  juice  of  four  lemons,  the 
rinds  of  two,  half  a  pint  of  sherry,  four  eggs,  six  ounces  of  loaf 
sugar,  one  pint  and  a  half  of  boiling  water. 

Pare  the  lemon  rind  thinly,  put  it  into  a  pitcher  with  the  sugar, 
59 


898  APPENDIX 

and  pour  the  boiling  water  on  it.  Let  it  cool,  then  strain,  and  add 
the  wine,  lemon  juice,  and  eggs,  previously  well  beaten  and  strained. 
Mix  all  together  and  it  is  ready  for  use. 

Savory  Custard  (Anderson). —  Add  the  yolks  of  two  eggs  to  a 
cupful  of  beef  tea,  with  pepper  and  salt  to  taste.  Butter  a  cup  or 
jam  pot,  pour  the  mixture  into  it,  and  let  it  stand  in  a  pan  of  boiling 
water  till  the  custard  is  set. 

Milk  for  Puddings  or  Stewed  Fruit  (Ringer). —  Boil  a  strip  of 
lemon  and  two  cloves  in  a  pint  of  milk;  mix  half  a  teaspoonful  of 
arrowroot  in  a  little  cold  milk  and  add  it  to  the  boiling  milk;  stir  it 
until  about  the  consistence  of  cream.  Have  ready  the  yolks  of  three 
eggs  beaten  up  well  in  a  little  milk.  Take  the  hot  milk  off  the  fire 
and  as  it  cools  add  the  eggs  and  a  tablespoonful  of  orange-flower 
water,  stirring  it  constantly  till  quite  cool.  Keep  it  in  a  very  cool 
place  till  required  for  use. 

Kice  Soup  (Ringer) . —  Take  three  ounces  of  rice,  the  yolks  of  two 
eggs,  half  a  pint  of  cream  or  new  milk,  one  quart  of  Stock. 

Boil  the  rice  in  the  stock  and  rub  half  of  it  through  a  tammy, 
put  the  stock  in  a  stewpan,  add  the  rest  of  the  rice  whole,  and  sim- 
mer gently  for  five  minutes.  Have  ready  the  milk  or  cream,  boiled. 
Beat  the  yolks  of  the  eggs  and  mix  them  gradually  with  the  cream. 
Take  the  soup  off  the  fire,  add  the  cream  and  egg,  stirring  them  well 
together  as  you  mix  them.  Heat  gradually,  but  do  not  boil,  or  the 
eggs  will  curdle. 

A  Gruel  (Ringer). —  Beat  an  egg  .to  a  froth,  add  a  wineglass  of 
sherry,  flavor  with  a  lump  of  sugar,  a  strip  of  lemon  peel,  and  a 
little  grated  nutmeg.  Have  ready  some  gruel,  very  smooth  and  hot, 
stir  in  the  wine  and  egg,  and  serve  with  crisp  toast.  Arrowroot  may 
be  made  in  the  same  way. 

Caudle  (Yeo). —  Beat  up  an  egg  to  a  froth;  add  a  glass  of  sherry 
and  half  a  pint  of  gruel.  Flavor  with  lemon  peel,  nutmeg,  and 
sugar. 

FARINACEOUS  FOODS 

Arrowroot  Blancmange  (Ringer). —  Take  two  tablespoonfuls  of 
arrowroot,  three-quarters  of  a  pint  of  milk,  lemon,  and  sugar  to 
taste. 

Mix  the  arrowroot  with  a  little  milk  to  a  smooth  batter ;  put  the 
rest  of  the  milk  on  the  fire  and  let  it  boil,  sweeten,  and  flavor  it, 
stirring  all  the  time,  till  it  thickens  sufficiently.  Put  into  a  mold 
till  quite  cold. 

Arrowroot   Blancmange    (U.   S.   Army   Hospitals). —  Two   table- 


FARINACEOUS  FOODS  899 

spoonfuls  of  arrowroot.     Two-thirds  pint  of  hot  water.     Two  table- 
spoonfuls  of  sherry  or  brandy.     Two  teaspoonfuls  of  sugar. 

Mix  the  arrowroot  into  a  smooth  paste  with  three  tablespoonfuls 
of  cold  water.  Add  this  to  the  hot  water.  Bring  to  a  boil,  stirring 
constantly  till  well  blended  and  free  from  lumps.  Let  it  boil  for  ten 
minutes.  Add  the  sugar  and  sherry  or  brandy.  Beat  up  quickly 
and  pour  into  a  bowl  or  mold  to  cool.  Arrowroot  blancmange  may 
be  made  with  fresh  hot  milk  or  condensed  milk  diluted.  If  boiling 
water  is  used  it  causes  the  starch  of  the  arrowroot,  when  first  poured 
in,  to  form  into  lumps.  Hence  it  is  best  to  have  the  water  not  quite 
at  boiling  point. 

Arrowroot  (Pavy). —  Mix  thoroughly  two  teaspoonfuls  of  arrow- 
root with  three  tablespoonfuls  of  cold  water,  and  pour  on  them  half 
a  pint  of  boiling  water,  stirring  well  meanwhile.  If  the  water  is 
quite  boiling,  the  arrowroot  thickens  as  it  is  poured  on,  and  nothing 
more  is  necessary.  If  only  warm  water  is  used,  the  arrowroot  must  be 
afterwards  boiled  until  it  thickens.  Sweeten  with  loaf  sugar  and  fla- 
vor with  lemon  peel  or  nutmeg,  or  add  sherry,  port  wine,  or  brandy,  if 
required.  Boiling  milk  may  be  employed  instead  of  water,  but  when 
this  is  done  no  wine  should  be  added,  as  it  would  otherwise  curdle. 

Oatmeal  Gruel  (plain)  (from  "Food"). —  Two  tablespoonfuls  of 
oatmeal,  one  saltspoonful  of  salt,  one  scant  teaspoonful  of  sugar,  one 
cupful  of  boiling  water,  one  cupful  of  milk.  Mix  the  oatmeal,  salt, 
and  sugar  together,  and  pour  on  the  boiling  water.  Cook  for  thirty 
minutes;  then  strain  through  a  fine  wire  strainer  to  remove  the  hulls, 
place  again  on  the  stove,  add  the  milk,  and  heat  just  to  the  boiling 
point.  Serve  hot. 

Scotch  Beef  Broth. —  To  a  pint  of  beef  broth  which  has  been  care- 
fully strained  and  seasoned  and  from  which  all  the  fat  has  been 
removed,  add  a  teaspoonful  of  oatmeal  and  boil  gently  for  two  hours. 
Strain  and  serve  hot. 

In  this  preparation  the  oatmeal  should  be  soft  and  jellylike,  and 
if  too  much  water  evaporates  during  the  boiling,  more  should  be 
added. 

Cornstarch  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Cornstarch,  six  ounces ;  milk,  three  pints ;  water,  twelve  ounces. 

Mix  the  cornstarch  into  a  smooth  paste  with  cold  water.  The  milk 
and  water  must  be  boiling,  to  which  add  a  little  salt.  Stir  in  the 
cornstarch.  Let  boil  three  or  five  minutes. 

Farina  Pudding  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Farina,  half  a  pound ;  milk,  two  pints ;  water,  one  pint ;  sugar,  two 
and  a  half  ounces;  eggs,  four  ounces;  nutmeg,  half  an  ounce. 


900  APPENDIX 

Put  the  water  into  a  stewpan  with  a  little  salt.  When  it  boils, 
stir  in  the  farina.  Let  it  boil  twenty  minutes.  Stir  in  the  milk, 
which  must  be  hot.  Beat  the  eggs  until  they  are  very  light;  mix  the 
sugar  with  them.  Stir  in  the  eggs  and  sugar  with  the  farina.  Add 
the  spice.  Put  it  into  a  moderate  oven  and  bake  a  half  or  three- 
quarters  of  an  hour. 

Farina  Gruel  (U.  8.  Army  Hospitals). —  One  tablespoonful  of 
farina.  One  pint  of  water.  One  teaspoonful  of  sugar.  One-half 
teaspoonful  of  salt.  Into  one  pint  of  water,  raised  to  boiling,  put 
a  half  teaspoonful  of  salt;  then  add  the  farina  and  cook  for  twenty 
minutes.  Flavor  with  sugar  and  condensed  milk,  if  fresh  milk  is 
not  available.  Strain  and  serve  hot. 

In  this  recipe,  as  in  others,  condensed  milk  is  used  in  a  strength 
of  one  teaspoonful  to  the  half  pint  of  gruel. 

Boiled  Rice  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Eice,  twelve  ounces;  salt,  half  an  ounce;  water,  three  pints. 

Put  the  salt  and  water  into  a  stewpan.  When  boiling,  add  the 
rice,  previously  thoroughly  washed.  Boil  for  ten  minutes,  or  until 
each  grain  becomes  soft.  Drain  on  a  colander.  Grease  the  stew- 
pan with  clarified  drippings  or  lard.  Put  back  the  rice.  Let  it  swell 
slowly  near  the  fire,  or  in  a  slow  oven,  for  about  twenty  minutes, 
until  the  grains  are  well  separated. 

Rice  Gruel  (Chambers).—  Ground  rice,  two  ounces;  powdered  cin- 
namon, quarter  of  an  ounce;  water,  four  pints.  Boil  forty  minutes 
and  add  a  teaspoonful  of  orange  marmalade. 

Rice  Gruel  (U.  S.  Army  Hospitals). —  Two  tablespoonfuls  of  rice, 
or  one  tablespoonful  of  rice  flour.  One  pint  of  boiling  water.  One- 
half  teaspoonful  of  salt.  One  teaspoonful  of  sugar.  Wash  the  rice 
thoroughly  in  two  waters,  after  removing  any  specks  that  may  be 
mixed  in  the  grain.  Have  the  cooking  water  boiling. 

Rice  Milk  (Anderson). —  Wash  two  tablespoonfuls  of  good  rice 
and  put  it  into  a  saucepan  with  a  quart  of  milk.  Let  it  simmer 
gently  till  the  rice  is  tender,  and  stir  from  time  to  time  to  prevent 
burning;  sweeten  to  taste.  If  desirable,  it  may  be  served  with 
stewed  apples  or  with  prunes.  Sago,  tapioca,  etc.,  are  prepared  in 
the  same  way.  If  an  egg  is  to  be  added,  beat  the  white  and  yolk 
separately,  and  add  them  to  the  rice  after  it  has  been  taken  from  the 
fire. 

Rice  and  Apple  (Pinger). —  Boil  about  two  tablespoonfuls  of  rice 
in  a  pint  and  a  half  of  new  milk,  and  simmer,  stirring  it  from  time 
to  time  till  the  rice  is  quite  tender.  Have  ready  some  apples,  peeled, 
cored,  and  stewed  to  a  pulp,  and  sweetened  with  a  very  little  loaf 


FARINACEOUS  FOODS  901 

sugar.  Put  the  rice  round  a  plate  and  the  apple  in  the  middle,  and 
serve. 

Rice  Cream  (Ringer] . —  To  a  pint  of  new  milk  add  a  quarter  of 
a  pound  of  rice,  a  lump  of  butter  the  size  of  a  walnut,  a  little  lemon 
peel,  and  a  tablespoonful  of  powdered  sugar.  Boil  them  together 
for  five  minutes,  then  add  half  an  ounce  of  isinglass  which  has  been 
dissolved,  and  let  the  mixture  cool.  When  cool  add  half  a  pint  of 
good  cream  whisked  to  a  froth,  mix  together,  and  set  it  for  a  time 
in  a  very  cool  place,  or  on  ice;  when  used,  turn  it  out  of  the  basin 
into  a  dish,  and  pour  fruit  juice  around  it,  or  some  stewed  apple  or 
pear  may  be  served  with  it. 

Rice  Cream  (from  "Food"). —  Two  tablespoonfuls  of  rice.  Two 
cups  of  milk.  One  saltspoonful  of  salt.  Two  tablespoonfuls  of 
sugar.  Two  eggs. 

Cleanse  the  rice  by  washing  it  several  times  in  cold  water;  cook 
it  in  a  double  boiler  with  the  milk  until  the  grains  will  mash.  Three 
hours  will  generally  be  required  to  do  this.  Should  the  milk  evap- 
orate, restore  the  amount  lost.  When  the  rice  is  perfectly  soft,  press 
it  through  a  coarse  soup  strainer  or  colander  into  a  saucepan,  return 
it  to  the  fire,  and  while  it  is  heating  beat  the  eggs,  sugar,  and  salt 
together  until  very  light.  When  the  rice  boils,  pour  the  eggs  in 
rather  slowly,  stirring  lightly  with  a  spoon  for  three  or  four  minutes, 
or  until  it  coagulates,  and  the  whole  is  like  a  thick,  soft  pudding; 
then  remove  from  the  fire,  and  pour  it  into  a  dish.  By  omitting  the 
yolks  and  using  the  whites  of  the  eggs  only,  a  delicate  cream  is 
obtained. 

Malt  (Ground)  and  Rice  Pudding  (Yeo). —  Stir  an  ounce  of  ground 
malt  into  a  pint  of  boiling  milk,  strain  through  a  sieve,  and  add 
the  milk  to  two  ounces  of  well-soaked  rice.  Mix  well,  and  stand  for 
ten  minutes  in  a  warm  place,  then  bake  for  an  hour.  This  makes  an 
excellent  predigested  food. 

Cracker  Gruel  (from  "Food"). —  Two  tablespoonfuls  of  cracker 
crumbs.  One  scant  saltspoonful  of  salt.  One  scant  teaspoonful  of 
sugar.  One  cup  of  boiling  water.  One  cup  of  milk. 

To  make  the  cracker  crumbs,  roll  some  crackers  on  a  board  until 
they  are  fine.  Water  crackers  are  good,  cream  crackers  are  better; 
mix  the  salt  and  sugar  with  the  crumbs,  pour  on  the  boiling  water, 
put  in  the  milk,  and  simmer  for  two  minutes.  The  gruel  does 
not  need  long  cooking,  for  the  cracker  crumbs  are  already  thoroughly 
cooked.  Do  not  strain. 

Indian-meal  Gruel  (from  "Food"). —  Two  teaspoonfuls  of  corn- 
meal.  One  tablespoonful  of  flour.  One  teaspoonful  of  salt.  One 


APPENDIX 

teaspoonful   of  sugar.     One   quart  of   boiling  water.     One  cup   of 
milk. 

Mix  the  cornmeal,  flour,  salt,  and  sugar  into  a  thin  paste  with 
cold  water,  and  pour  into  it  the  boiling  water.  Cook  in  a  double 
boiler  for  three  hours.  No  less  time  than  that  will  cook  the  corn- 
meal  thoroughly.  Then  add  the  milk,  and  it  is  ready  to  serve. 

Hard-bread  Gruel  (U.  S.  Army  Hospitals). —  Toast  hard  bread 
thoroughly  and  grind  it  into  a  powder.  To  one  pint  of  boiling  water, 
to  which  one-half  teaspoonful  of  salt  has  been  added,  add  two 
tablespoonfuls  of  hard-bread  powder.  Boil  ten  minutes  and  then 
strain.  Flavor  with  one  teaspoonful  of  sugar  and  one  teaspoonful 
of  condensed  milk  to  each  cupful  of  the  gruel. 

Bread  Jelly  (Chrystie). —  Pour  boiling  water  on  stale  bread,  and 
let  it  soak  for  an  hour.  Pour  off  the  water,  add  fresh  water,  and 
boil  down  until  a  thick  mass  is  obtained  which  becomes  jellylike 
on  cooling,  and  may  be  eaten  with  milk  or  cream  and  sugar. 

Milk  Porridge  (U.  S.  Army  Hospital  Receipt  for  Twelve  Men). — 
Milk,  eight  pints ;  flour,  twelve  ounces ;  water,  three  pints. 

The  flour  to  be  used  for  milk  porridge  should  previously  be  pre- 
pared by  being  tied  up  closely  in  a  bag  and  boiled  four  or  five  hours. 
It  can  then  be  grated  to  a  powder,  which  should  be  mixed  into  a 
smooth  paste  with  cold  water.  Add  to  the  milk  the  prescribed  quan- 
tity of  water,  and  stir  in  the  flour,  with  a  little  salt.  Let  it  boil  ten 
minutes,  stirring  all  the  time. 

Fothergill's  Amylaceous  Food. —  Of  rice,  well  washed,  of  arrow- 
root, tapioca,  and  pearl  barley,  take  each  an  ounce,  add  two 
quarts  of  water,  and  boil  down  to  a  quart;  then  flavor  with  candied 
eringo. 

Barley  Jelly  (Eustace  Smith). —  Put  two  tablespoonfuls  of  washed 
pearl  barley  into  a  pint  and  a  half  of  water,  and  slowly  boil  down 
to  a  pint;  strain,  and  let  the  liquid  settle  into  a  jelly.  Two  tea- 
spoonfuls  of  this,  dissolved  in  eight  ounces  of  warmed  and  sweet- 
ened milk,  are  enough  for  a  single  feeding,  and  such  a  meal  may  be 
allowed  twice  a  day. 

Panada  (Ringer). —  Take  the  crumb  of  a  penny  roll  and  soak  it 
in  milk  for  half  an  hour,  then  squeeze  the  milk  from  it;  have  ready 
an  equal  quantity  of  chicken  or  veal,  scraped  very  fine  with  a  knife; 
pound  the  bread  crumb  and  meat  together  in  a  mortar.  It  may 
be  cooked  either  mixed  with  veal  or  chicken  broth,  or  poached  like 
an  egg.  By  taking  it  up  in  two  spoons,  in  pieces  the  shape  of  an 
egg,  after  seasoning,  it  may  be  served  with  mashed  potato. 

Another  Caudle   (Ringer). —  Mix  well  together  one  pint  of  cold 


MILK-SUGAR  PREPARATIONS  903 

gruel  •  with  a  wineglassf ul  each  of  good  cream  and  sherry  and  a 
tablespoonful  of  noyau,  and  sweeten  with  sugar  candy. 

Almond  Cakes  for  Diabetics  (Seegen). —  Take  of  blanched,  sweet 
almonds  a  quarter  of  a  pound,  beat  them  as  fine  as  possible  in  a 
stone  mortar;  remove  the  sugar  contained  in  this  meal  by  putting 
it  into  a  linen  bag  and  steeping  it  for  a  quarter  of  an  hour  in  boiling 
water  acidulated  with  vinegar;  mix  this  paste  thoroughly  with  three 
ounces  of  butter  and  two  eggs.  Next  add  the  yolks  of  three  eggs 
and  a  little  salt,  and  stir  well  for  some  time.  Whip  up  the  whites 
of  three  eggs  and  stir  in.  Put  the  dough  thus  obtained  into  greased 
molds  and  dry  by  a  slow  fire. 

Macaroni  Boiled  (U.  8.  Army  Hospital  Receipt  for  Twelve  Men}. 
—  Macaroni,  one  pound ;  salt,  a  quarter  of  an  ounce ;  boiling  water, 
six  pints.  Wipe  the  macaroni  carefully.  Break  into  four-inch 
lengths.  Put  with  the  salt  into  cold  water  and  boil  until  tender,  but 
not  until  it  bursts  or  becomes  a  pulp.  Drain  off  the  water  at  once, 
and  season  with  butter.  The  liquor  from  the  macaroni  makes  a  good 
broth. 

MILK-SUGAR  PREPARATIONS 

Following  are  receipts  devised  by  Miss  Cutler,  Dietitian  to  Belle- 
vue  Hospital,  for  "  forced  feeding,"  and  for  the  special  Coleman- 
Shaffer  diet  for  typhoid  fever,  described  on  p.  478. 

Cocoa  With  Milk. 

1  teaspoon  of  cocoa. 

2  tablespoons  of  milk-sugar. 
4     oz.  milk. 

2     oz.  cream. 

Mix  the  sugar  and  cocoa,  cook  in  the  milk  until  dissolved.  Serve  with  the 
cream. 

Cocoa. 

1  teaspoon  of  cocoa. 

2  tablespoons  of  milk-sugar. 
J     cup  water. 

3  oz.  cream. 

Mix  the  cocoa  and  sugar,  add  the  water  and  boil  4  or  5  minutes.  Then  add 
the  cream  or  use  less  cream  and  serve  with  whipped  cream. 

Coffee. 

1J  tablespoons  milk-sugar. 

4  to  5  oz.  strong  coffee. 
2     oz.  cream. 

Plain  Junket  or  Rennet  Custard. 
1     tablespoon  milk-sugar. 

5  oz.  milk. 

\     junket  tablet. 
1     oz.  cold  water. 

Few  drops  vanilla.     See  directions  for  Cocoa  Junket. 


904  APPENDIX 

Cocoa  Junket. 

1     teaspoon  cocoa. 

1     tablespoon  milk-sugar. 

5  oz.  milk. 

4     junket  tablet  dissolved  in  1  oz.  cold  water. 

Mix  the  cocoa  and  sugar,  add  milk  and  heat  lukewarm,  stirring  constantly, 
add  the  dissolved  junket,  stir  thoroughly  and  leave  in  a  warm  place,  to  set. 

Lemonade. 

1  to  8  tablespoons  milk-sugar. 
7     oz.  cold  water. 

2  tablespoons  lemon  juice. 

Boil  the  sugar  and  water  2  minutes.  Add  lemon  juice  to  taste,  strain  and 
cool. 

Soft  Custard. 
1     cup  of  milk. 

1  egg. 

2  tablespoons  of  milk-sugar. 
Speck  of  salt. 

2  or  3  drops  of  vanilla  or 

Caramel  made  of  3  tablespoons  of  granulated  sugar. 

Beat  the  egg  slightly,  add  sugar,  salt  and  hot  milk  slowly.  Cook  in  a 
double  boiler,  stirring  constantly,  until  it  thickens  a  little.  (If  cooked  too 
long,  the  custard  will  curdle,  but  may  be  made  smooth  again  if  set  in  a  dish 
of  cold  water  and  beaten  at  once).  Flavor  and  cool. 

Baked  Custard. 

1J  tablespoon  milk-sugar. 

6  oz.  milk. 
1     egg. 

Nutmeg  or  vanilla. 
Speck  of  salt. 

Beat  egg  slightly.  Warm  the  sugar  and  the  milk,  stirring  constantly,  add 
to  the  egg,  strain  into  a  custard  cup  and  flavor.  Bake  in  a  pan  of  water  in  a 
moderate  oven  until  a  knife,  when  cut  into  it  will  come  out  clean.  (30  min. 
to  1  hr.). 

Bread  Pudding. 

1J     tablespoons  milk-sugar. 

6     oz.  milk. 

1     egg. 

1     slice  of  bread   (|  in.  thick). 

\     oz.  butter. 

Spread  the  bread  with  the  butter  and  cut  into  squares.  Beat  the  egg 
slightly:  heat  the  milk  and  sugar,  stirring  constantly,  mix  with  the  egg  and 
pour  over  the  bread.  Grate  nutmeg  over  the  top  and  bake  the  same  as  the 
custard. 

GELATIN  PREPARATIONS 

Port-wine  Jelly  (Ringer) . —  Put  into  a  jar  one  pint  of  port  wine, 
two  ounces  of  gum  arabic,  two  ounces  of  isinglass,  two  ounces  of 
powdered  white  sugar  candy,  a  quarter  of  a  nutmeg  grated  fine,  and 
a  small  piece  of  cinnamon.  Let  this  stand  closely  covered  all  night. 
The  next  day  put  the  jar  into  boiling  water  and  let  it  simmer  until 
all  is  dissolved,  then  strain,  let  stand  till  cold,  and  then  cut  into 
small  pieces  for  use. 

Milk,  Rum,  and  Isinglass  (Ringer). —  Dissolve  in  a  little  hot  water 


GELATIN  PREPARATIONS  905 

over  the  fire  a  pinch  of  the  best  isinglass;  let  it  cool,  and  mix  a 
dessertspoonful  of  rum  with  it  in  a  tumbler,  and  fill  up  the  glass 
with  new  milk. 

Nutritious  Coffee  (Ringer). —  Dissolve  a  little  isinglass  in  water, 
then  put  half  an  ounce  of  freshly  ground  coffee  into  a  saucepan  with 
one  pint  of  new  milk,  which  should  be  nearly  boiling  before  the 
coffee  is  added;  boil  both  together  for  three  minutes;  clear  it  by 
pouring  some  of  it  into  a  cup  and  dashing  it  back  again,  add  the 
isinglass,  and  leave  it  to  settle  on  the  hob  for  a  few  minutes.  Beat 
up  an  egg  in  a  breakfast  cup,  and  pour  the  coffee  upon  it;  if  pre- 
ferred, drink  it  without  the  egg. 

Lemon  Jelly  (U.  S.  Army  Hospitals). —  One-fourth  box  of  gelatin 
(one-half  ounce).  One-fourth  cup  of  cold  water.  One-fourth  cup  of 
fresh  lemon  juice  (about  the  amount  yielded  by  two  lemons).  Three 
tablespoonfuls  of  sugar.  One  and  one-fourth  cups  of  boiling  water. 
Put  the  gelatin  to  soak  in  the  cold  water,  about  twenty  minutes  be- 
ing required  for  this  process.  When  dissolved,  pour  on  the  boiling 
water.  Add  the  lemon  juice  and  sugar.  Stir  thoroughly  and  strain 
through  a  fine-meshed  cloth  into  a  china  or  granite-ware  mold, 
cooling  in  a  refrigerator  or  by  placing  in  a  pan  of  cold  water.  Xever 
use  tin  molds  for  lemon  jelly. 

Coffee  Jelly  (U.  S.  Army  Hospitals). —  One-fourth  box  of  gela- 
tin (one-half  ounce).  One-fourth  cup  of  cold  water.  One  cup  of 
boiling  water.  One-half  cup  of  strong  coffee.  Two  tablespoonfuls  of 
sugar.  Soak  the  gelatin  in  the  cold  water  for  half  an  hour.  Pour 
on  the  boiling  water,  then  put  in  the  sugar  and  coffee.  Strain  it 
through  a  cloth  into  a  mold  or  dish  in  which  it  may  be  cooled, 
either  in  a  pan  of  iced  water  or  in  a  refrigerator.  Coffee  jelly  may 
be  served  with  cream  and  sugar. 

Have  the  coffee  strong,  two  tablespoonfuls  of  coffee  to  each  cup 
of  water.  Where  vanilla  extract  is  available,  one-half  teaspoonful 
may  advantageously  be  added  to  the  above  recipe. 

Wine  Jelly  (U.  S.  Army  Hospitals). —  One-fourth  box  of  gelatin 
(one-half  ounce).  One-fourth  cup  of  cold  water.  One-half  cup  of 
sugar.  One-half  cup  of  sherry  wine.  One  and  one-fourth  cup  of 
boiling  water.  One  small  piece  of  cinnamon.  Put  the  gelatin  and 
cold  water  together  in  a  dish  large  enough  to  hold  the  whole  mix- 
ture. Let  it  soak  for  half  an  hour,  then  pour  the  boiling  water  (in 
which  the  piece  of  cinnamon  has  been  simmering)  over  the  softened 
gelatin.  Add  the  sugar  and  wine,  strain  through  a  clean  cloth  into  a 
china  or  granite-ware  mold,  and  cool  in  a  refrigerator  or  a  pan 
of  cold  water. 


906  APPENDIX 

FAT  FOODS 

(Useful  in  diabetes  and  in  emaciation  not  due  to  gastrointes- 
tinal disorder,  such  as  that  of  chronic  phthisis  and  chronic  sepsis, 
empyema,  etc.) 

Fresh  butter,  one-quarter  pound  or  more  per  diem;  suet,  lard, 
margarine,  and  "  drippings "  used  in  excess  in  cooking,  fat  soups 
and  broths,  rich  cheese,  Devonshire  clotted  cream,  cream  diluted  with 
water  or  Vichy  to  the  consistency  of  milk,  and  drunk  as  a  beverage 
(a  pint  or  more  per  diem),  olives,  olive  oil  on  salads,  sardines,  etc.; 
fat  fish,  such  as  mackerel  and  salmon ;  the  fats  of  Bussell's  Emulsion, 
cod-liver  oil,  oily  nuts,  such  as  fresh  English  walnuts,  butter- 
nuts, pecan,  and  Brazil  nuts;  bacon,  pork,  fat  ham,  fat  tongue,  fat 
goose  and  duck,  and  any  form  of  fat  meat,  such  as  the  tender  fat  of 
corned  beef,  bone  marrow,  egg  yolk. 

CONCENTRATED  FLUID  NOURISHMENT 

(Sometimes  useful  in  fevers  and  conditions  in  which  only  very 
small  quantities  of  food  can  be  taken.) 

1.  Milk,  peptonized,  to  which  is  added  in  each  tumblerful  one 
or  two  tablespoonfuls  of  (1)  milk  sugar  (first  dissolved  in  hot  water), 
(2)  the  albumen  of  one  or  two  eggs,  (3)  a  tablespoonful  of  malted 
milk,  Nestle's,  Carnrick's,  Benger's,  or  other  proprietary  food  dis- 
solved in  milk. 

2.  Meat  juice  squeezed,  or  strong  broths,  to  which  may  be  added 
one   of  two  teaspoonfuls   of   such   concentrated   foods   as   Plasmon, 
Mosquera's  Beef  Meal,  Nutrose,  or  Somatose,  or  Imperial  Granum 
Sanatogen,  or  one  of  the  fluid  beef  preparations,  such  as  Johnson's 
Fluid  Beef,  etc. 

3.  Cream,  half  a  tumblerful,  with  the  albumen  of  one  egg  and 
a  teaspoonful  of  some  cordial,  such  as  Curagoa  or  Benedictine,  and  a 
teaspoonful  of  milk  sugar.     (Suitable  especially  for  consumptives.) 

SUBSTITUTES  FOR  THE  MORNING  TEA  OR  COFFEE 

Patients  often  insist  upon  having  some  form  of  hot  drink  to 
replace  the  breakfast  cup  of  tea  or  coffee  of  which  they  have  been 
deprived.  There  is  no  true  substitute  for  these  beverages  in  the 
sense  that  their  mildly  stimulating  effects  are  replaced,  but  the  habit 
of  taking  "  something  hot "'  with  the  first  meal  may  be  satisfied  by 
use  of  one  of  the  following: 


SUBSTITUTES  FOR  TEA  AND  COFFEE        907 

Hot  water  flavored  with  lemon  and  cloves;  hot  malted  milk,  hot 
cocoa,  cocoa  nibs,  chocolate,  or  alkathrepta;  a  cup  of  hot  broth  or 
of  hot  water,  with  addition  of  a  teaspoonful  of  some  meat  extract  like 
Liebig's  or  Valentine's  Meat  Juice.  There  are  also  the  artificial 
"  coffees,"  made  from  parched  grains,  beans,  etc.,  which  are  much  ad- 
vertised, and  one  made  from  torrefied  bananas;  caudle;  gruels  made 
with  Irish  or  Iceland  moss  and  spiced,  or  flavored  with  lemon. 


INDEX 


Abscess  of  liver,  653. 

Absinthe,  287. 

Absorption,  food,  399. 

Acid,  acetic,  292;  boric,  314,  315; 
citric,  207;  hydrochloric,  387; 
hydrochloric,  free,  574;  lactic, 
57;  malic,  207;  tartaric,  207. 

Acid  test  for  milk,  64. 

Acidity  of  gastric  juice,  574. 

Acidosis,  758. 

Acids,  organic,  207;   vegetable,  48. 

Acidulous  waters,  246. 

Acne,  685. 

Acorns,  227. 

Acute  gastritis  in  children,  588. 

Acute  nephritis  in  children,  546. 

Addison's  disease,  767. 

Adult  life,  food  in,  353. 

Adulteration  of  food,  427;  of  liquors, 
286;  of  milk,  70. 

Aerated  bread,  167. 

Age  and  food,  322. 

Albumen,   121. 

Albumen  water,  122. 

Albumin,  57;  vegetable,  390. 

Albuminoids,  estimation  of,  70. 

Albuminuria,  functional,  547;  organ- 
ic, 547. 

Albumoses,    389. 

Alcohol,  262;  absorption  of,  269; 
action  of  on  circulation,  270;  on 
digestion,  268;  on  muscles,  267; 
on  temperature,  267 ;  and  climate, 
269;  as  a  diuretic,  267;  as  a 
food,  265;  as  a  heart  stimulant, 
270;  as  a  nerve  stimulant,  266; 
as  a  tonic,  270;  clinical  uses  of, 
270;  elimination  of,  269;  force 
value  of,  264 ;  hypodermic  use  of, 
269;  in  fevers,  271;  in  gout,  762; 
in  nervous  diseases,  271;  physio- 
logical action  of,  265;  poisoning 


by,  438;  in  tuberculosis,  510;  in 
typhoid  fever,  481;  uses  of,  263. 

Alcoholic  beverages,  272. 

Alcoholism,  438;  treatment  for,  440, 
441. 

Ale,  268,  275. 

Alewife,  149. 

Alimentary   canal   diseases,   563. 

Alimentary  pastes,   180. 

Alkaline  purges,  246. 

Alkaline    sulphur   waters,   246. 

Alkaline  water  in  diabetes,  755. 

Alkaline  waters,  245. 

Allantiasis,   420. 

Allegheny  General  Hospital  diet, 
872. 

Allspice,  292. 

Almond  cakes,  751,  903. 

Almond  oil,  234. 

Almonds,   226. 

Alum  in  food,  314. 

Amylaceous  foods,  173. 

Anacidity,   393. 

Anaesthesia,  diet    after,  772. 

Anasarca,  556. 

Anemia  and  rheumatism,  771 ;  die- 
tetic treatment  of,  539;  perni- 
cious, 543;  rest  and  exercise  in, 
539;  symptoms  of,  538. 

Anemias,  537;  dietaries  for,  542; 
physiology  of,  537. 

Aneurism,  535. 

Angina  pectoris,  533. 

Angiocholitis,   649. 

Angostura,  287. 

Animal  and  vegetable  foods  com- 
pared, 29. 

Animal   viscera,    145. 

Anise,  287. 

Anisette,   288. 

Annoto,   429. 

Anti-fat  remedies,  710. 


909 


910 


INDEX 


Antiscorbutics,  206. 

Antiseptics  and  foods,  313. 

Apollinaris,  245. 

Apoplexy,  677. 

Appendicitis,  643. 

Appendix,  887. 

Appetite,  368;  in  illness,  444. 

Appetite  juice,  370. 

Applejack,   285. 

Apple  sauce,  215. 

Apples,  208,  209,  214. 

Apricots,   208,   209,   214. 

Arabs'  diet,  319. 

Argol,  278. 

Army  diets,  779. 

Army  hospital  dietaries,   880. 

Army  prison  diet,   793. 

Army  ration,  Austrian,  786;  British, 
786;  foreign,  786;  French,  786, 
789;  German,  789;  Italian,  788; 
Russian,  789;  Spanish,  788; 
United  States,  789. 

Arnold's  sterilizer,  97. 

Aromatic   herbs,   290. 

Arrack,  285. 

Arrowroot,  186. 

Arrowroot  blancmange,  898. 

Arterio-sclerosis,  534. 

Arthritis  deformans,  714. 

Artichokes,   203;    Jerusalem,    199. 

Artificial  digestion,  396. 

Artificial   infant  foods,   840. 

Ascaris  lumbricoides,  413. 

Ascites,  651. 

Asitia,  343. 

Asparagus,  204. 

Associated  diseases,  diet  in,   770. 

Ass's  milk,  63. 

Asthma,   521. 

Ataxia,   locomotor,  676. 

Athletic  training,  809. 

Atrophy,  simple,   629. 

Austrian  Army  ration,  786. 

Autointoxication.  621;  dietetic  sum- 
mary for,  623-625. 


Babcock's  cream  tester,  68,  69. 

Racillac,    92. 

Bacillus        acidilactici,        77, 


101; 


Bacillus  botulinus,  419;  bulgaris,  91; 
butyricus,  420;  tuberculosis,  434. 

Bacon,  142. 

Bacteria  in  infant  stools,  616;  in 
milk,  75,  80;  in  the  stomach, 
579;  thermal  death,  point  of,  in 
milk,  100. 

Baking,  303;   bread,   164. 

Baking  powders,  167. 

Balfour's  diet  for  the  senile  heart, 
531. 

Banana  flour,  218. 

Bananas,  208,  216. 

Bananose,   218. 

Bandaging   and    constipation,    641 ; 

Banting  system,   697. 

Barley,  184. 

Barley  jelly,  902. 

Barley  milk,  102. 

Barley  water,  887. 

Bass,    148,    149. 

Bean,  kidney,    194. 

Beans,  194;  kidney,  194;  red,  194; 
soya,  194;  vanilla,  292. 

Beanjolais,  283. 

Beechnuts,  226. 

Beef,  boiled,  297;  canned,  313; 
chipped,  131;  composition  of, 
130;  concentrated,  131;  corned, 
309;  "embalmed,"  316;  fluid, 
889;  powdered,  133;  prepara- 
tions of  for  the  sick,  131;  rare, 
301;  refrigerated,  310;  roast, 
299;  smoked,  309. 

Beef  blood,  134. 

Beef  broth,  138. 

Beef  essence,  890. 

Beef  extract,  131,  891;  South  Ameri- 
can, 135. 

Beef  fat,  131,  232. 

Beef  jelly,  133. 

Beef  juice,  135,  136,  889. 

Beef  meal,  132. 

Beef  peptones,  139. 

Beef  peptonoids,  134. 

Beef  tea,  89,  136. 

Beef  tongue,  141. 

Beer,  268,  274;  Bavarian.  275:  brew- 
ing of,  274;  English,  268;  lager, 
268;  white,  275. 


INDEX 


911 


Beet  sugar,  154. 

Beets,    199. 

Bellevue   Hospital  dietary ,  866. 

Benedictine,   287. 

Benger's  extract,  141. 

Benger's  food,    176. 

Benger's  ^peptones,   139. 

Benger's  peptonized  beef  jelly,  133. 

Beri-beri,  676. 

Berries,  221. 

Beverages,      241,      887;       demulcent 

and  nutritive,  887 ;   diuretic  and 

refrigerant,  888;  use  of  in  fevers, 

468;     in    lithsmia,    562;     milk, 

889. 

Bicycle  rider's  diet,  815. 
Biedert's  cream  mixture,  896. 
Bilberries,  222. 
Bile,  394. 
Biliousness,  646;  directions  for  eating 

in,    648;    dietetic    treatment    of, 

647. 

Birds'  nests,   147. 
Biscuits,  173.  178;  casoid,  750;  meat, 

894;   pilot,  179;  ship,  179. 
Bitter  milk,  73. 
Blackberries,  208,  209,  222. 
Blackwheat,  180. 
Blair's  wheat  food,   174. 
Blancmange,  898. 
Blood,  146;  diseases  of,  537. 
"  Blossom  "  fat  food,  235. 
Blueberries,  222. 
Boar,   145. 

Boas'  test  breakfast,  573. 
Boas'  test  for  free  hydrochloric  acid, 

574. 
Boat    crew    dietary,    Harvard,    812; 

Yale,  811. 
Boat    crews,    dietary,    summary    of, 

814. 

Bob  veal,  420. 
Body  weight  and  food,  324. 
Boiled  beef,  296. 
Boiled  fish,  298. 
Boiled  milk,  86. 
Boiled  water,  40. 
Boiling,  296. 
Boils,  691. 


Bone  marrow,  233. 

Borage,  203. 

Borax,  315. 

Bordeaux   wine,  283. 

Boric  acid  in  food,  314;  in  milk,  72. 

Bottle  feeding,  833. 

Bottled  milk,   100. 

Bottles,  nursing,  843. 

Botulism,  420. 

Bouchard's  system,  705. 

Bouillon,  137,  297,  892. 

Bourbon  whiskey,  285. 

Bovine  tuberculosis,  432. 

Bovinine,  139. 

Brain  food,  372. 

Brain  workers'  diet,  819. 

Brains,  146,  233. 

Braise,  302. 

Braising,   302. 

Bran,  162;  and  potato  bread,  748. 

Brandy,  285. 

Brazil  nuts,  226. 

Bread,  161;  aerated,  167;  bran,  750; 
composition  of,  164;  compressed, 
306;  diabetic,  748;  dried,  306; 
for  children,  858;  gluten,  172, 
748;  Graham,  171;  inulin,  751; 
making  of,  161;  protene,  750; 
pulled,  178;  rice,  184;  rye,  181; 
soya,  752;  spoiled,  168;  substi- 
tutes for  in  diabetes,  747;  whole- 
meal, 170. 

Bread  jelly,  178,  902. 

Bread  pudding,  904. 

Brewing,  274. 

Brie,  117. 

Bright's  disease,  acute,  554;  causa- 
tion of,  550;  chronic,  550;  treat- 
ment of,  551. 

Brine,  309. 

British  army  hospital  dietaries,  884. 

Broccoli,  202. 

Broilers,   143. 

Broiling,  300. 

Bronchitis,  capillary,  520;  chronic, 
520. 

Bronchopneumonia,  525. 

Broth,  138. 

Broths,  891. 


912 


INDEX 


Brussels  sprouts,  202. 

Buckwheat,   160,   180. 

Bulimia,  370;   and  dyspepsia,  584. 

Burgundy,  280,  281,  283. 

Burnet,  203. 

Butter,    112. 

Butter,  cacao,  259. 

Butter  fat,  56. 

Butter   fish,    149. 

Butterine,  232. 

Buttermilk,  114. 

Butternuts,  226. 

Cabbages,  201. 

Cacao  butter  oil,  234. 

Caffeine,  252. 

Calcium,  47. 

Calcium-carbonate  test,  575. 

Calculi,  biliary,  653;  renal,  558;  vesi- 

cal,  558. 

Calf's  foot  jelly,  147. 
Calorie,  31,  361. 
Calorimeter,  9. 
Camembert,  116. 
Camplin's  bran  bread,  750. 
Candies,  adulterated,  428. 
Candy  for  children,  859. 
Cane  sugar,   154. 
Canned   beef,   421. 
Canned  foods,  153. 
Canning,   312. 
Cantaloupe,  223. 
Capers,  203,  291. 
Capillary  bronchitis,  520. 
Capon,   143. 
Capsicum   annuum,  291;   fastigiatum, 

291. 

Caramel.  156. 

Carbohydrates,  19,  25 ;  in  obesity,  693. 
Carbonated  milk,  96. 
Carbonic  acid  in  bread,  165. 
Carbonic  waters.  244. 
Carcinoma     of     oesophagus,     566;     of 

stomach,  611. 
Cardiac    valvular     disease.     528;     in 

children.  530. 
Carnrick's    food,    107,    178;    peptones, 

139. 
Caroid,   3P9. 


Carp,   149. 

Carrots,  200. 

Casein,  57;  vegetable,  192,  390. 

Casoid  biscuits,  750. 

Cassava,   187. 

Catsup,  293. 

Caudle,  898. 

Cauliflower,  202. 

Caviare,  120. 

Cayenne  pepper,  291. 

Celery,  203. 

Celulose,   14. 

Centrifugal   machine,    110,    111. 

Cepe,  225. 

Cereal  coffee,  257. 

Cerealin,  170. 

Cerealine,  182. 

Cereals,  159;  composition,  160;  in 
chronic  constipation,  636. 

Cerebrospinal  meningitis,  495. 

Certified  milk,  80. 

Cetraria  Icelandica,  187,  225. 

Chablis,   281. 

Chalybeate  waters,  246. 

Champagne,  281,  284. 

Champagne  cider,  288. 

Chantreul,  225. 

Chapman's  dipper,  56. 

Chartreuse,  287,  288. 

Cheddar,  116. 

Cheese,  114;  poisoning  by,  423; 
ripening  of,  116;  varieties  of, 
115. 

Cheese  food,  19. 

Chemical  analysis  of  a  man,  1. 

Chervril,  203. 

Cheshire  cheese,   117. 

Chestnuts,   226. 

Chicago  sanitary  flour,  751. 

Chicca,  182. 

Chicken,  143. 

Chicken  broth,  891. 

Chicken  jelly,  894. 

Chicory,  203,  256. 

Childhood,  food  in,  352. 

Children,  diarrhoea  in,  614;  diet  for 
school,  854;  dietaries,  848;  in 
English  hospitals,  878;  dyspepsia 
in,  585;  food  for,  845;  intestinal 


INDEX 


913 


indigestion  in,  626;    sample  diet 

for,  857;  starchy  foods  for,  188; 

typhoid  fever  in,  487. 
Chilies,  291. 
Chipped   beef,   131. 
Chittenden's  diet,  336. 
Chive,  203. 
Chlorosis,  538. 

Chocolate,  260;  casoid,  750;   for  dia- 
betics, 752;   uses  of,  261. 
Cholera,  infection  of  food,  436,  437; 

prophylaxis,       497 ;       symptoms, 

498;  treatment,  498. 
Cholera  infantum,  619. 
Cholera  morbus,  620. 
Chorea,  673. 

Chronic  diarrhoea  in  children,  627. 
Chronic  gastritis,  milk  diet  in,  591. 
Chronic    gastrointestinal    catarrh    in 

children,  627. 

Chronic  nephritis  and  ascites,  771. 
Chronic  nephritis  and  diabetes,  770. 
Chronic  nephritis  and  obesity,  771. 
Chrystie's  beef  tea,  890. 
Cider,  288. 
Cinnamon,  291. 

Circulation  and  digestion,  374. 
Circulatory    diseases    and    diet,    527, 

528. 

Cirrhosis,  650. 
Citrons,  223. 
Citrus  pomelanus,  213. 
Clabberade,  96. 
Clams,  151. 
Claret,  278,  283,  284. 
Climate  and  alcohol,  269;   and  food, 

318. 

Clothing  and  food,  321. 
Clotted  cream,  111. 
Cloud  berries,  766. 
Clouty  cream,  77. 
Cloves,  292. 

Cochin  Hospital  dietary,  877. 
Cocoa,  258,  903;  adulteration  of,  260. 
Cocoanut  oil,  234. 
Cocoanuts,  226. 
Cod,  148,  149. 
Cod-liver  oil,  236 ;   administration  of. 

237;  dosage,  237;  inunction,  240. 

458;    properties  of,   236;    substi- 
60 


tutes  for,  239;  in  tuberculosis, 
509. 

Coefficient  of  digestibility,  8,  26. 

Coffee,  adulteration  of,  256,  429; 
composition  of,  252;  ill  effects 
of,  255;  nutritious,  905;  physio- 
logical action  of,  254;  prepara- 
tion of,  253;  quantity  of  con- 
sumed, 256;  substitutes  for,  257, 
906;  and  tea  compared,  257; 

Coffee   jelly,    905. 

Cognac,  285. 

Cold  storage,  310. 

Cole,  202. 

Coleman  and  Shaffer's  diet  for  ty- 
phoid fever,  478. 

Colitis,  chronic,  625;  membranous, 
630. 

College  diets,  821. 

Colostrum,  61,  832. 

Commercial  life,  diet  in,  823. 

Compote,  211. 

Concentrated  food,  305;  fluid,  906; 
concentrated  wines,  283. 

Condensed  cream,   111. 

Condensed  milk,  unsweetened,   108. 

Condiments,  288;  harmful  effects  of, 
289. 

Confectionery,   156. 

Consomme",  893. 

Constipation,  chronic,  633;  in  infants, 
641;  pathology  of,  634;  symp- 
toms of,  635;  treatment  for, 
636. 

Convalescence  in  typhoid  fever,  483- 
485. 

Convalescent  diet  in  fevers,  472,  893. 

Cook  County  Hospital  dietary,  873. 

Cooking,  294;  for  diabetics,  753;  of 
eggs,  123;  of  fish,  304;  of  meat, 
303 ;  varieties  of,  295 ;  vegetables, 
304. 

Cordials,  287. 

Corn,    181. 

Corn   meal,    160,    182. 

Corn   starch,   182,   899. 

Corn   syrup,    183. 

Cornaro's  diet,  345. 

Corpulence,  691,  698. 

Corpulency  and  gout,  719. 


914 


INDEX 


Cost  of  food,  28. 

Cottage  cheese,   116. 

Cottolene,  231. 

Cotton  seed  oil,  234. 

Courgettes,  205. 

Cowpeas,  192,  193. 

Cows,   unhealthy,   73. 

Crab-apples,  215. 

Crabs,  150. 

Cracked  wheat,  178. 

Cracker  gruel,  901. 

Crackers,    160,    178. 

Cranberries,  205. 

Craving,   abnormal,   for  foods,  370. 

Cream,  54-109;  centrifugal,  110: 
clotted,  111;  clouty,  77;  condensed. 
Ill;  Devonshire,  111;  estimation 
of,  66;  evaporated,  111;  poison- 
ing by,  423;  separator,  110. 

Cream   cheese,    116. 

Cream-of-tartar  drink,  889. 

Creamometer,   67. 

Cress,   203. 

Crimping,    150. 

Crustaceans,   150;    poisoning  by,  424. 

Crystalose,  753. 

Cucumbers,  204. 

Cuisine,   231. 

Curacoa,   287,   288. 

Curds,  82,  83. 

Cure,  dry,  807;  fruit,  804;  grape, 
805 ;  koumiss,  802 ;  meat  and  hot 
water,  806;  reduction  for  obesity, 
708;  rest,  667;  skimmed  milk. 
795;  whey,  801. 

Cures,   dietetic,   803. 

Currant  jelly,  889. 

Currants,  202.  211,  222. 

Curry  powders,   289. 

disk.  149. 

Custard,  904. 

Dahi.  435. 

Dairies,   79. 

Dandelion.  202. 

Darby's    fluid   meat.    133. 

Dates.  223. 

Debove's  forced  feeding,  515. 

Declorinated   diet.  556. 

Decorticated    flour,    172. 


Delirium  tremens,  442. 

Dementia,  678. 

Demulcents,   242,   887. 

Dentition,   abnormal,   563. 

Dermatitis,  exfoliative.  689. 

Desiccated   eggs,    124. 

Desiccated   vegetables.   306. 

Desiccation,   305. 

Desserts  for  children,  851 

Deutero-albumose,  389. 

Devonshire  cream,   111. 

Dextrin,  153. 

Dextrinized  foods,  173.  177. 

Dextrose,   154. 

Diabetes,  diagnosis  of,  739 ;  dietetic 
treatment  of,  740;  Diiring's  diet 
for,  756 ;  Ebstein's  diet  for,  755. 
foods  allowed  in,  744;  foods  for- 
bidden in,  747;  and  gout.  730; 
hygienic  treatment  of,  757;  later 
symptoms  of,  737;  medicinal 
treatment  of,  758;  Naunyn's 
diet  for,  757;  and  nephritis,  770; 
and  pancreas,  733;  physiological 
experiments,  731 :  prognosis  of, 
738 ;  symptoms  of,  735 ;  theories, 
734;  urine  in,  736;  varieties  of, 
742,  743;  von  Noorden's  diet  for, 
757. 

Diabetes  mellitus,  729. 

Diabetic  beverages,  754. 

Diabetic  coma,  758. 

Diabetic   diet,   755;   Thompson's.   746. 

Diaphanometer,  67. 

Diarrhoea,  613;  in  children,  chronic, 
627;  in  infants,  614;  physiology 
of,  613;  summer,  617. 

Diastase,  188,  396. 

Diathesis,  gouty,  721. 

Dibothriscephalus  latus,   149,  415. 

Diet,  broth,  864;  convalescent,  862; 
"cures"  for  phthisis,  517;  fish, 
864;  for  bicycle  riders,  815;  for 
brain  workers,  819;  for  football 
players.  815;  for  forced  feeding, 
515,  516;  for  jockeys,  815;  for 
nursing  mother,  829;  for  puer- 
peral women,  826;  for  pugilists. 
815:  for  school  children.  854;  for 
surgical  patients,  772;  for  wet 


INDEX 


915 


nurse,  829;  and  habit,  36;  half, 
862;  house,  862;  improperly  bal- 
anced, 350;  in  abnormal  denti- 
tion, 563;  in  athletic  training, 
809;  in  commercial  life,  823;  in 
disease,  463;  in  diseases  of  the 
alimentary  canal,  563;  in  dis- 
eases of  the  circulation,  527;  in 
diseases  of  the  nervous  system, 
658;  in  miscellaneous  diseases, 
767;  in  prisons,  792;  in  relation 
to  operations,  772;  in  skin  dis- 
eases, 682;  light,  862;  milk,  50, 
862;  minimum,  352;  non-nitrog- 
enous, 862;  of  concentrated 
foods,  307;  proteid,  862;  and 
rest,  327;  salt-free,  556;  soft, 
445;  variety  in,  371;  and  urine, 
543. 

Diet  absolue",  775. 

Diet-kitchen  outfit,  462. 

Dietaries,  777;  of  hospitals,  861;  of 
United  States  Army  hospitals, 
880-884;  standard,  17,  20,  27,  28, 
796,  797. 

Dietary  of  Harvard  boat  crew,  812; 
of  Yale  boat  crew,  811;  rules  for 
prescribing,  409. 

Dietetic  difficulties  in  associated  dis- 
eases, 770. 

Dietetic  errors,  410. 

Digestibility  of  food,  363. 

Digestion,  abnormal,  392;  artificial, 
396;  and  circulation,  374;  and 
emotion,  382;  and  exercise,  377; 
and  the  nervous  system,  373; 
and  rest,  380;  and  sleep,  380; 
and  temperature,  374;  and 
wines,  284 ;  duration  in  stomach, 
390;  in  intestine,  393;  in  mouth, 
382;  of  fats,  394;  of  meats,  128; 
of  milk,  82;  of  proteids  in  stom- 
ach, 389. 

Dilatation  of  the  stomach,  596. 

Dinner  courses,  364. 

Diphtheria,  493. 

Diseases  caused  by  dietetic  errors, 
410;  especially  influenced  by 
diet,  691. 

Disinfection  of  food  utensils,  449. 


Distilled  water,  39. 

Diuretic  beverages,  888. 

Dough,   166. 

Doura,   181. 

Drugs  in  human  milk,  61,  830. 

Dry  diet,  305,  330,  536,  807. 

Duck,   144. 

Duckworth's  diet  for  gout,  724. 

Dujardin-Beaumetz's  diet  for  obesity, 
704. 

Dujardin-Beaumetz's  test  breakfast, 
573. 

During's  diet  for  diabetes,  726. 

Dutch  cheese,  116. 

Dysentery,   631. 

Dyspepsia,  568;  and  anemia,  585; 
atonic,  584;  beverages  in,  581; 
dietetic  treatment  of,  579; 
etiology  of,  569;  flatulent,  584; 
foods  allowed  in,  581;  foods  for- 
bidden in,  580;  general  rules, 
583;  gouty,  584;  in  infants,  585; 
irritative,  584;  nervous,  584; 
special  treatment  for,  582. 

Dysphagia,  565. 

Ebstein's  diabetic  diet,  755. 

Ebstein's   obesity   diet,   697. 

Economic  value  of  food,  25. 

Eczema,  685;  in  children,  689  j  in 
nursing  infants,  688. 

Edam  cheese,   118. 

Eels,    148. 

Egg  albumen,  122. 

Egg  preparations,  897. 

Eggnogg,   122,  897. 

Eggplant,  204. 

Eggs,  120,  233;  and  albuminuria, 
548;  boiled,  123;  composition  of. 
124;  cooking  of,  123;  dried,  305; 
in  fevers,  467;  preservation  of, 
124;  raw,  122;  test  for  fresh- 
ness, 121;  white  of,  123. 

Elderberry,  222. 

Electricity  and  constipation.  641 ;  in 
neurasthenia,  671. 

Elements,  chemical,  1. 

Elimination  of  food  waste,  400. 

Embalmed  beef,  316. 

Embryonine,  750. 


916 


INDEX 


Emergency  ration,  785. 

Emphysema,  522. 

Empyema,  526. 

Emulsions,  237. 

Endive,  203. 

Enemata,  450;  alcohol  in,  457;  blood, 

456;    eggs  in,  457;    grape  sugar 

in,  457;  method  of  injection,  452; 

of  meat  and  pancreas,  456,  894; 

of  milk,  457. 
Energy  from  food,  6. 
English  hospital  dietaries,  children's, 

878. 

Enteralgia,  662. 
Enteritis,      acute      catarrhal,      620; 

chronic,   in  adults,   625. 
Enterocolitis  in  children,  617,  627. 
Epilepsy,  674. 
Erbswurst,  193. 
Ergotism,  426. 
Erysipelas,  496. 
Erythema,   684. 
Eskay's  food,  135,  178. 
Eskimo  diet,  358. 
Essence,  beef,  891. 
Evaporated   cream,   111. 
Evaporated  eggs,  124. 
Ewald    and    Siever's    test    for    motor 

power  of  stomach,  578. 
Exercise     and     digestion,     377;     and 

food,  322;   and  obesity,  801. 
Exophthalmic  goitre,  768. 
Extract    of    beef,    891;    of    pancreas, 

190,  398. 
Extractives,    126. 

Extracts  of  foods,  305.  '. 

Extractum  carnis,   138. 

Famine,    350. 

Farina,   178. 

Farina  gruel,  900. 

Farinaceous  foods,  161,  173,  898. 

Farinaceous  gruels  in  typhoid  fever, 
478. 

Fasting,   voluntary,    344. 

Fat,  of  beef,  131;  of  butter,  56;  of 
milk,  54. 

Fat   foods.  331.  906;   in  obesity.  693. 

Fats,  19,  228;  animal,  231;  digesti- 
bility of,  230;  in  anemias.  541; 


in  diabetes,  744;  in  gout,  722; 
in  neuralgia,  659;  uses  of,  228, 
239,  235;  vegetable,  234. 

Feces,  from  bread,  172;  examination 
of  diarrhoeal,  616;  and  food,  401. 

Feeding  children,  general  rules  for, 
847;  adults,  general  rules  for, 
444;  forced,  340,  515;  help- 
less patients,  447;  hypodermic, 
459;  intra  vascular,  458;  in- 
fants, 841;  rectal,  450;  and 
sleep,  853;  the  sick,  444;  uncon- 
scious patients,  449. 

Fermentation,  intestinal,  621. 

Ferments  in  foods,  309. 

Fever,  diet  in,  463,  465;  milk  in,  466; 
pathological  physiology  of,  463. 

Fevers,  alcohol  in,  470;  beverages  in, 
478;  intermittent,  503;  remit- 
tent, 503. 

Fig  wine,   288. 

Figs,  208,  233. 

Filberts,  226. 

Filtered  water,  39. 

Fining,  279. 

Tinkler's  proteid  food,  134. 

Fish,  147;  dried,  305;  poisoning  by, 
424;  roe,  150;  smoked,  309. 

Fish  oils,  233. 

Fisher's  endurance  tests,  385. 

Flatulency,  584. 

Flaxseed  tea,  889. 

Fletcherism,  384. 

Flies,  food  infection  by,  437. 

Flounder,  148,  149. 

Flour,  160,  161;  ball,  174;  banana, 
218;  casoid,  749;  gluten,  748; 
malt,  189;  wheaten,  169. 

Fluid  beef  preparations,   889. 

Fluids   in  circulation   diseases,   528. 

Food,  absorption  of,  399;  adultera- 
tion of,  427;  age  and,  322,  329, 
352,  353;  and  anaesthetics,  772; 
animal,  29-33;  calorifacient,  5; 
carbohydrate,  5 ;  and  cholera  in- 
fection, 436 ;  classification  of,  4 ; 
climate  and,  318;  clothing  and, 
321;  concentration  of,  305;  con- 
densed, 305;  containing  para- 
sites, 413;  cost  of,  27,  28;  crav- 


INDEX 


917 


ings  for,  370;  details  of  serving, 
446;  elementary  composition  of, 
1;  elimination  of,  400;  enemata, 
458;  equivalents  for,  322,  404; 
exercise  and,  322;  factors,  322; 
and  feces,  401;  for  young  chil- 
dren, 845;  force  producing  value 
of,  19;  improperly  balanced,  413; 
in  childhood,  352;  infection 
through  diphtheria,  437 ;  infec- 
tion through  scarlatina,  437 ;  in 
the  intestine,  393;  measurement 
of,  341;  and  medicines,  459;  ni- 
trogenous, 5 ;  non-nitrogenous,  5 ; 
order  of  taking,  364;  and  oxy- 
gen, 24;  percentage  composition 
of,  15,  16;  physical  properties 
of,  4  ;•  poisons,  425 ;  portions, 
404;  preservation  of,  308;  pro- 
teid,  4;  and  ptomaines,  419; 
quantity  of  required,  317,  333, 
334,  quantity  per  annum,  340; 
and  race,  358;  in  relation  to 
special  diseases,  407 ;  respira- 
tory, 5;  restriction  of,  336; 
and  salicylic  acid,  314;  sea- 
son and,  318;  sex  and,  323; 
size  of  body,  and,  324 ;  sleep,  and, 
479;  source  of,  4;  stimulating, 
25;  substitutes  for,  316;  teeth- 
ing and,  853;  temperature,  375, 
377;  and  tobacco,  404;  and  ty- 
phoid fever,  435;  and  urine,  403; 
vegetable,  34,  190;  waste,  400; 
water-free,  330;  and  weight,  324. 

Foods,  animal,  49;  artificial  infant, 
840;  classes  of,  36;  concentrated, 
307;  farinaceous,  173;  and  idio- 
syncrasies, 438;  malted,  189; 
National  Bureau  of,  430;  pro- 
prietary, 173;  vegetable,  152. 

Foot-and-mouth    disease,    74,    437. 

Football  dietaries,  815. 

Force  production,  5. 

Forced  feeding,  340,  515;  in  insanity, 
678,  681. 

Foreign  bodies   swallowed,  567. 

Formaldehyde,  316. 

Fowl,  143. 

Freeman's  pasteurizer,  102. 


Freezing  of  foods,  310. 

French  army  hospital  dietaries,  885. 

Frijole,   194. 

Fromentine,  750. 

Fruit,  dried,  211;  when  to  eat,  211. 

Fruit  essences,  243. 

Fruit  ripening,  210. 

Fruit  sirups,  243,  244. 

Fruit  soups,  212,  466. 

Fruit  sugars,  207. 

Fruits,  207;  composition  of,  207; 
cooked,  211;  digestibility,  212;  in 
chronic  constipation,  637;  in 
gout,  723;  poisoning  by,  210; 
properties  of,  209;  uses  of,  209; 
varieties  of,  212. 

Frying,  301. 

Fuel  value  of  food,   13,  27,  28,  361. 

Fungi,  224;  in  milk,  76;  poisonous, 
225. 

Furunculosis,  681. 

Fusel  oil,  287. 

Gaduin,  236. 

Gaertner's  mother  milk,  107. 

Galactase,  97. 

Gallstones,  653. 

Game,  144;  poisoning  by,  419,  422. 

Garlic,  205. 

Gases  in  dyspepsia,  569. 

Gastralgia,  661. 

Gastrectasia,   596. 

Gastric  atony,  576. 

Gastric  catarrh,  in  children,  596; 
dietetic  summary  for,  595. 

Gastric   contents,   577. 

Gastric  digestion,  390. 

Gastric  fistula,  566. 

Gastric  juice,  386,  387,  574. 

Gastritis,  acute,  586,  587;  chronic, 
593,  594,  589. 

Gastrodynia,  661. 

Gavage,  608,  837. 

Gelatin,  146;  and  milk,  89;  prepara- 
tions of,  904. 

Gerber's  food,  177. 

German  army  ration,  789. 

Germs  in  food,  308,  313;  in  milk,  73, 
74. 

Gin,  286. 


918 


INDEX 


Ginger,  292. 

Ginger  ale,  243,  244. 

Globulin,   182. 

Glucose,   157. 

Gluten,  163;  vegetable,  190. 

Gluten  bread,  748. 

Gluttony,  317. 

Glycerides  of  cream,  109. 

Glycerin,  235;  in  diabetes,  753. 

Glycogen,  23. 

Glycosuria,  739. 

Goats,  145. 

Goat's  milk,  62. 

Goitre,  exophthalmic,   768. 

Gonorrhoea,  562. 

Goose,  144. 

Gooseberries,  208,  222. 

Gorgonzola,   118. 

Gout,  715;  aids  to  treatment  of, 
728;  chronic,  721;  and  diabetes, 
730;  dietetic  treatment  for,  719; 
Duckworth's  diet,  724;  and 
obesity,  771;  preventive  treat- 
ment for,  717;  symptoms  of,  717; 
theory,  718. 

Gouty  diathesis,  721. 

Graham  bread,    171. 

Graham  flour,  160. 

Grain  of  corn,  182;  of  wheat,  162, 
163. 

Grain  poisoning,  426. 

Granose,   179. 

Granum,  174. 

Grape  cure,  805. 

Grape  fruit,  213. 

Grape  juice,   158. 

Grapes,  208,  209,  219. 

Gravel,  559. 

Green  gages,  220. 

Green  vegetables,  191. 

Greens,   191,  202. 

Grilling,  300. 

Groats,    185. 

Grocer's  itch,  155. 

Grog  de  la  poudre  de  viande,   133. 

Ground  pear,  199. 

Grouse,  144. 

Gruels.  161,  808-902;  farinaceous, 
478. 

Gruyere.   118. 


Guava,  215. 
Guinea  fowl,  144. 
Gum,  209. 
Gunzberg's  test,  574. 

Habit,  and  diet,  36;  in  eating,  860. 

Haddock,   148,  149. 

Halibut,  148,  149. 

Ham,  142. 

Hard-tack,  179. 

Haricots,  194. 

Hasheesh,  317. 

Hazel  nuts,  226. 

Health  and  food,  333. 

Heart,  145;  senile,  530. 

Heart  disease  in  children,  530. 

Hemorrhage  of  lungs,  519. 

Hemorrhoids,  643. 

Hepatalgia,  662. 

Herb  teas,  243. 

Herbs,  aromatic,  290. 

Heredity  and  diet,  357. 

Herring,  149. 

Heteroalbumose,  389. 

Hickory  nuts,  226. 

Hock,  284. 

Hoff's  malt  extract,  189. 

Holt's  dietaries  for  infants,  850,  851 ; 

lactometer,    67;     milk    formulas, 

106;   milk  measuring  glass,   106; 

schedule  for  infant  feeding,  840. 
Hominy,  182. 
Honey,  158. 
Horlick's  food,  176. 
Horse  flesh,  143. 
Horse-radish,  203,  293. 
Hospital  army  dietaries,  880. 
Hospital  dietaries,  864,  866,  870-872. 
Hours  for  meals,  364,  856. 
Huckleberries,  222. 
Hunger,  348. 

Hydrochloric  acid,  free,  574. 
Hyperacidity,     393;     and     dyspepsia, 

584. 

Hypersecretion,  392,  576. 
Hypoacidity,  393. 
Hypodermic    feeding,   459. 

Ice,  44. 

Ice  cream,  112;  poisoning  by,  423. 


IXDEX 


919 


Iceland  moss,  187,  225. 

Ichthysrnus,  425. 

Ideal  mother's  milk,  107. 

Idiosyncrasies  in  dyspepsia,  569;  and 
food,  438. 

Imperial  granum,  174. 

Inanition,   343. 

Indian  corn,   181. 

Indian  meal,   183. 

Indigestion,  568;  intestinal,  in  chil- 
dren, 626. 

Infancy,  diet  in  first  year,  840. 

Infant  food,  Liebig's,   175. 

Infants,  constipation  in,  641 ;  diar- 
rhoea in,  614;  eczema  in,  688; 
enterocolitis  in,  617.;  feeding  of. 
830,  832;  feeding  of  by  wet 
nurse,  832 ;  premature,  844. 

Infection  of  milk,  432. 

Infectious  diseases,  diet  in,  473. 

Infectious  germs  and  food,  432. 

Influenza,  491. 

Insalivation,    383. 

Insane,  diet  for,  876. 

Insanity,  acute,  678. 

Insects,   152. 

Insomnia,  672. 

Intermittent  fever,  503. 

Intestinal  antisepsis  and  typhoid 
fever,  482. 

Intestinal   autointoxication,  621. 

Intestinal  catarrh,  625. 

Intestinal  gases,  395. 

Intestinal  indigestion  in  children, 
626. 

Intestinal  obstruction,   632. 

Intestinal  worms,  413. 

Intestines,  digestion  in,  393 ;  in  ty- 
phoid fever,  483. 

Intoxication,  alcoholic,  439. 

Intravascular  feeding,  458. 

Intravenous  injection  of  milk,  81. 

Intubation,  493. 

Inulin  biscuits,   752. 

Inunction  foods,  458. 

Iron.  48. 

"  Iron  ration,"  193. 

Isinglass.   146. 

Italian  army  ration,  788. 

Italian  paste,  180. 


Jam,  222. 

Jaundice,  acute  catarrhal,  649. 

Java  almond  oil,  234. 

Jellies,  147,  222. 

Jerusalem  artichoke,   199. 

Jockey's  diet,  815. 

Johannis   water,   244,   245. 

Johannisberg,  279. 

Johns  Hopkins  Hospital  dietary,  873. 

Junket,  895. 

Kaiserin  Friedrich's  Children's  Hos- 
pital dietary,  879,  880. 

Kakke",  676. 

Kalodal,   459. 

Kava,  263. 

Kean's  tropical  ration,  783. 

Keating's  diet  for  neurasthenia,  670. 

Kefir,  95. 

Kepler's  extract  of  malt,  189. 

Kidneys,  145. 

Kirsch,   285. 

Klemperer's  test  for  motor  power  of 
stomach,  579. 

Kneipp  system,  804. 

Kohl   rabi,   200. 

Kola,  262. 

Koumiss,  93,  94,  896;  home  made, 
94. 

Koumiss  cure,  802. 

Koumys,  93. 

Koumysgen,  95. 

Kiilz's  inulin  biscuits,  752. 

Kiimmel,  287. 

Lactalbumen,  57. 

Lactated  food,  107,  177. 

Lactic  acid,  57. 

Lactobacilline,  92. 

Lactometer,    Holt's,    67;    Quevenne's, 

66. 

Lactone,  65,  93. 
Lacto-preparata,  107. 
Lactoscope,  67. 
Lactose.  56,  70,  134,  158. 
Lager  beer,  268. 
Lamb,  142. 

Laparotomy,  diet  after,  775. 
Lard,  231. 

Laryngismus  stridulus,  518. 
Laryngitis,  tubercular,  518. 


920 


INDEX 


Lathyrism,  426. 

Lavage,  598,  601. 

Lead  poisoning,  419,  430c 

Leanness,  diet  for,  710. 

Leaven,  165. 

Leben   raib,  96. 

Lebert's  milk  cure,  514. 

Lecithin,  233. 

Leeks,  205. 

Legumes,    192. 

Legumin,  91,  750. 

Lemon  jelly,   905. 

Lemonade,  212,  889;  effervescing,  889. 

Lemons,  208,  212. 

Lentils,  195. 

Lettuce,  203. 

Leube's    soluble   meat,    609;    test   for 

motor  pow.er  of  stomach,  578. 
Levulose,  158. 

Leyden's   diet  for  neurasthenia,   669. 
Lichen,  225. 
Liebig's  extract,   138. 
Liebig's  foods,  175. 
Lima  beans,  194. 
Limburger,  117. 
Lime,  saccharated,  89. 
Lime    water,    home    made,    896,    and 

milk,  89. 
Limes,  213. 
Linseed  oil,  234. 
Linseed  tea,  889. 
Lipanin,  240. 
Lipase,  98. 
Liqueurs,  287. 
Liquid  diet,  237. 
Liqucr  pancreaticus,   140. 
Liquorice,  293. 
Liquors,    284;    adulteration    of,    286; 

malt,  274;   uses  of,  286. 
Litchi  nuts,  227. 
Lithsemia,   559. 
Liver,  145;  abscess  of,  654;   amyloid, 

G54;  diseases  of,  646;  fatty,  652; 

syphilis  of,  654. 

Liverpool   Infirmary   dietary,   878. 
Lobsters,   150. 
Locomotor  ataxia,  676. 
Loeflund's  cream  emulsion,   177;   malt 

extract,    189. 
Lying-in,  diet  for,  826. 


Maazoun,  95. 

Macaroni,   160,  180,  903. 

Macaroons,  226. 

Mace,  292. 

Mackerel,  148,  149. 

Madeira,  279,  280. 

Maize,  181. 

Maizena,  182. 

Malaga,  280. 

Malaria,   503. 

Malarial  cachexia,  503. 

Malmsey,  280. 

Malt,  274,  397. 

Malt  extracts,  188. 

Malted  foods,  176. 

Malted  milk,  107,  177. 

Maltine,  189. 

Maltose,  158. 

Mango,   216. 

Mania,  678,  877. 

Manioc,   187. 

Mannite,  158. 

Maple  sugar,  155. 

Maranta  arundinacea,  186. 

Marasmus,  629. 

Marchand's  process,  67. 

Mare's  milk,  63,  94. 

Marrow,  bone,  233;   vegetable,  205. 

Massage,  602 ;  and  chronic  constipa- 
tion, 640. 

Mastication,  383. 

Mate",  257. 

Materna,   106. 

Matzol,  95. 

Matzoon,  95. 

Maurel's  standard  diet,  339. 

Meal,  Indian,  183. 

Meals,  hours  for,  264,  367. 

Measles,  490. 

"  Measles,"  415. 

Measurement   of   foods,   342. 

Measures  for  food,  342. 

Meat,  consumption  of,  124;  dried, 
305;  extracts  of,  138,  .891;  for 
children,  859;  and  hot  water 
cure,  806;  in  anemias,  541;  in 
epilepsy,  674 ;  in  gout,  722 ;  in 
obesity,  693;  infection  by  tu- 
bercular, 434;  jerked,  306;  poi- 
soning by,  419;  preparations  of 


INDEX 


921 


fluid,  135;  preparations  of  solid, 
132,  893  j  raw,  132,  354;  smoked, 
309. 

Meat  bases,  126. 

Meat  biscuit,  894. 

Meat   extractives,    126. 

Meat  lozenges,  134. 

Meats,  124;  canned,  312;  comparative 
digestibility  of,  129;  composition 
of,  126,  127;  digestibility  of, 
128;  raw,  127. 

Medicines,  and  food,  459;  rules  for 
administration  of,  461. 

Melancholia,  678,  680,  877. 

Mellin's  food,  176. 

Melons,  222. 

Meningitis,  cerebrospinal,  495. 

Metal  poisoning,  430. 

MSteil,  181. 

Metschinkoff  on  milk,  91. 

Migraine,  662. 

Military  foods,  307. 

Milk,  49;  adaptation  of  for  the  sick, 
84;  adulteration  of,  71;  albumin- 
ized, 895;  alkalies  with,  88; 
amylaceous  foods,  88,  177;  anal- 
ysis, 60-63;  artificial  human, 
895;  bacteria  in,  80;  blue,  76; 
care  of,  in  infant  feeding,  835 ; 
certified,  80;  and  cinnamon 
drink,  894;  color  of,  64;  color- 
ing matter  in,  71,  72;  composi- 
tion of,  52,  54;  condensed,  108; 
contamination  of,  70,  72;  cow's, 
58;  derivatives  of,  108;  digestion 
of,  82;  dilution  of,  with  aer- 
ated water,  87;  diphtheria 
and,  76;  and  disease  germs, 
73;  diuretic  action  of,  81; 
dried,  305;  drugs  in,  61;  estima- 
tion of  solids  in,  65;  fat  of,  54; 
ferments  in,  58 ;  flavor  of,  64 ; 
frozen,  53;  human,  59;  human, 
drugs  in,  830;  humanized,  103; 
impurities  in,  70;  in  acute  ne- 
phritis, 545;  in  chronic  nephritis, 
551-554;  in  fever,  466;  in  gout, 
721;  in  tuberculosis,  513;  in  ty- 
phoid fever,  474 ;  infection  by, 
432;  infection,  acute,  619;  in- 


fection, prophylaxis  of,  77;  infec- 
tion, tubercular,  432 ;  lead  poison- 
ing and,  81;  malted,  177; 
methods  of  altering  taste  of, 
85;  mode  of  administration, 
476;  modified,  103,  105;  odor 
of,  64;  pancreatinized,  80; 
pasteurized,  100;  peptonized,  101 ; 
physical  properties  of,  51;  poison- 
ing by,  423 ;  and  poisonous  foods, 
72;  predigestion  of,  90;  prepara- 
tions of,  894;  prescriptions,  104, 
105;  reaction  of,  64;  quantity  in 
typhoid  fever,  475;  and  salt,  88; 
skimmed,  86,  795 ;  souring  of,  77 ; 
specific  gravity  of,  66;  sterilized, 
96;  substitutes  for,  477;  substi- 
tutes for  in  infant  feeding,  836; 
sugar  preparations  of,  903; 
thickening,  72;  typhoid  fever, 
and,  75;  uses  of,  81;  variations 
in  composition  of,  60;  varieties 
of,  58 ;  of  various  breeds  of  cows^ 
106;  woman's,  58. 

Milk  Commission,  74,  80. 

Milk  foods,  107. 

Milk  laboratories,  103. 

Milk  punch,  895. 

Millet,  181. 

Mineral  waters,  243. 

Mint,  203,  293. 

Mitchell,  Weir,  and  neurasthenia, 
668;  and  obesity,  703. 

Mixed  feeding  for  infants,  837. 

Molasses,   157. 

Molasses  candy,  156. 

Morel,  225. 

Morrhuol,  239. 

Moselle,  281. 

Mosquera's  beef  jelly,  133 ;  beef  meal, 
132. 

Mouth,  care  of  infant's,  844;  care  of 
in  typhoid  fever,  483;  cleansing 
of,  448;  food  in  the,  382. 

Mucous  disease,  630. 

Mulberries,  222. 

Mulled  wine,  280. 

Mullet,   149. 

Mumps,  490. 

Muscarin,  225. 


922 


INDEX 


Mush,   183. 
Mushrooms,  206. 
Muskmelon,  223. 
Mussel  poisoning,  424. 
Mussels,  151,  152. 
Must,  279. 
Mustard,  290. 
Mutton,  141. 
Mutton  broth,  892. 
Mutton  fat,  232. 
Mytilotoxin,  424. 

Nageli's  condensed  milk,  108. 

Nasturtium,  203. 

Naunyn's  diabetic  diet,  757. 

Navy    ration,    British,    792;    United 

States,   790. 
Nectarines,  208,  215. 
Nephritis,    acute,    544;    chronic,    550, 

555. 

Nervous  prostration,  664. 
Nervous  system,   diet  in  diseases  of, 

658. 

Nestles  milk  food,  107,  177. 
Neufchatel,   117. 
Neuralgia,  658 ;  visceral,  660. 
Neurasthenia,  664 ;  dietetic  treatment 

for,   667 ;    general  treatment   for, 

665;   summary  of  foods  for,  671. 
New  York  Hospital  dietary,  864. 
New  York  Infirmary  dietary,  874. 
New    York    State    Hospital    dietary, 

875. 

Nitrogen  balance,  21. 
Nitrogen  lag,  21. 
Nitrogen  output,  403. 
Nitrogenous  food,  331. 
Northeastern    Hospital    for    Children 

dietary,   879. 
Nucleins,  500. 
Nursing  mother's  diet,  829. 
Nut  flour,  751. 
Nutmeg,  292. 
Nutrients,  23,  53. 
Nutrition,  29. 
Nutrose.  119. 
Nuts,  220.  227,  234. 

Oatmeal,  185;   in  diabetes.  757. 
Oatmeal  flour.   10S. 


Oatmeal  gruel,  898. 

Oats,  185. 

Obesity,  691;  Bouchard's  system  in, 
705;  Chambers'  system  in,  706; 
Debove's  system  in,  707 ;  dietetic 
'  treatment  for,  694,  701 ;  Dujar- 
din-Beaumetz  system  in,  704 ;  and 
exercise,  801;  and  gout,  771;  and 
nephritis,  771;  Oertel's  diet  for, 
699,  701;  preventive  dietary  for, 
708 ;  Schweninger  system  in,  702 ; 
summary  of  dietetic  treatment 
for,  707;  von  Noorden's  system 
in,  705;  Weir-Mitchell  system  in, 
703;  Yeo's  system  in,  703. 

Obstruction,   acute   intestinal,    632. 

Occupation  and  diet,  817,  818. 

Oertel  system,  699,  701. 

Oesophagus,  carcinoma  of,  566;  stric- 
ture of,  566. 

Oidium  lactis,  76. 

Oils,  228;  vegetable,  234. 

Okra,  203. 

Oleo  oil,  232. 

Oleomargarine,  232. 

Olive  oil,  234;  for  gallstones,  657. 

Olives,  208,  221. 

Omelette,  124. 

Onions,  205. 

Operations,  diet  for,  772. 

Opium  in  enemata,  455. 

Orangeade,   889. 

Oranges,  208,  213. 

Osteomalacia,  768. 

Osteotoxismus,  425. 

Ovariotomy,  diet  after,  775. 

Overdrinking,  412. 

Overeating,  411;    and  eczema,  686. 

Overfeeding,  863;  of  infants,  831. 

Oxaluria,  557. 

Ox-tail,   147. 

Oxydase,  97. 

Oxygen,  24. 

Oyster  crackers,  179. 

Oyster  plant,  200. 

Oysters,  151,  152;  and  typhoid  fever, 
435 ;  poisoning  by,  425. 

Palpitation,  533. 
Panada,  902. 


IXDEX 


923 


Pancreatic  disease,  657. 

Pancreatic  extract,   190, 

Pancreatic  juice,  394. 

Pancreatic  solution,  90. 

Pancreatin,  398. 

Pancreatinized  foods,  398. 

Panopeptone,  140. 

Papoid,   399. 

Paprika,  293. 

Paralysis,  post  diphtheritic,  495. 

Parasites  in  food,  413. 

Parsley,  203. 

Parsnips,   200. 

Partridge,  144. 

Pastes,  180. 

Pasteurizing  plant,  101. 

Pastry,  173. 

Pea  sausage,  193. 

Pea  soup,  193. 

Peaches,  208,  215. 

Peafowl,  144. 

Peanut  oil,  234. 

Peanuts,  195,  227. 

Pearl  sago,  187. 

Pearl  tapioca,   187. 

Pears,  208,  215. 

Peas,  192. 

Pecan  nuts,  226. 

Pectase,  207. 

Pectose,  207. 

Pellagra,  427. 

Pemmican,  233,  333,  334. 

Pepper,    black,    290;    cayenne,    290; 

white,  290. 
Peppergrass,  203. 
Peppermint,  287,  293. 
Peppers,  203. 

Pepsin,  388,  397;  test  for,  576. 
Pepsinogen,  388. 
Peptones,  139,  389,  398. 
Peptonized  foods,  398. 
Peptonizing  powders,  90. 
Peptonoids,  134. 
Perch,  149. 

Peritonitis,  acute,  645;  chronic,  645. 
Peristalsis,  390. 
Pernicious  anemia.  543. 
Pheasant,   144. 
Phosphorus,  48. 
Phytolacca  berries,  710. 


Pickerel,  149. 

Pickles,  293,  313. 

Pieplant,  204. 

Pigeons,  144. 

Pigments,  429. 

Pilot   biscuits,   179. 

Pine  nuts,  226. 

Pineapple  cheese,  117. 

Pineapples,  208,  215. 

Pistachio,  227. 

Plant  casein,  192. 

Plasmon,  119. 

Playfair's  diet  for  neurasthenia,  669. 

Pleurisy,  525. 

Plums,  208,  209,  220. 

Pneumonia,  523. 

"  Poison  Squad,"  314. 

Poisoning,  alcohol,  438;   cheese,  423; 

copper,    430;    cream,    423;     fish, 

424;  game,  419,  422;  grain,  426; 

ice-cream,    423;    lead,    419.   430; 

meat,  419;  metal,  430;  milk,  423; 

mussel,      424;      ptomaine,     421; 

sausage,  420;  tin,  430;  zinc,  430. 
Poisons  of  food,  425. 
Poland  water,  244. 
Polar  expedition  diet,  321,  333. 
Polenta,  182. 
Pollack,  149. 
Poluboskos,  173,  750. 
Polysarcia,   691. 
Pomegranate,  208,  216. 
Pomelo,  213. 
Pompano,   149. 
Porgy,  149. 

Pork,  142;  fat  of,  232. 
Porridge,  902. 
Port,  279,  280. 
Port  wine  jelly,  904. 
Porter,  275. 
Posset,  889. 
Pot  au  fteu,  137. 
Potassium  salts,  47. 
Potatoes,  196;   sweet,  199,  206. 
Pot-cheese,  116. 
Prairie  chicken,  144. 
Pregnancy,  diet  in,  825. 
Prepared  baby  foods,  840. 
Presbyterian  Hospital  dietary,  868. 
Prescribing  dietaries,  777. 


924 


IXDEX 


Preservatives  and  foods,  313;  of  milk, 

72. 

Prickly  pear,  223. 
Prison     diet,     792;     United     States 

Army,  793. 
Proenzyme,  388. 
Professional  man's  diet,  820. 
Proof  spirit,  285. 
Propepsin,  388. 
Proprietary  foods,  840. 
Proteid,  6. 
Proteids,  19;  digestion  of  in  stomach, 

389;  predigestion  of,  397. 
Protein,  6. 

Protene  diabetic  bread,  750. 
Prunelles,  208,  211. 
Prunes,  208,  220. 
Pruritus,  690. 
Prussian    Army    Hospital     dietaries, 

885. 

Psoriasis,  690. 
Ptomaine  poisoning,  421 
Ptomaines,  419. 
Puberty  and  diet,  855. 
Puddings,  173. 
Puerperal  women's  diet,  826. 
Puffed  rice,  184. 
Puffed  wheat,  184. 
Pugilist's  diet,  815. 
Pulmonary  hemorrhage,  519. 
Pulque,  241. 
Pumpernickel,  171. 
Pumpkins,  205. 
Pure"e,  meat,  138. 
Purees,  466. 
Purin-free  diet,  808. 
Purpura-hemorrhagica,  767. 
Purslane,  203. 
Purveyors  of  food,  462. 
Putrefaction,     420;     intestinal,     621, 

622 

Pyelitis,  556. 
Pyrosis,  393 

Quail.   144. 

Quantity  of  food,  for  children,  847;  in 
illness,  445 ;  for  single  meals,  406. 
Quevenne's  lactometer,  66. 
Quince,  215. 
Quinsy,  564. 


Rabbit,  143. 

Rabies,  505. 

Race  and  diet,  358. 

Radishes,  200. 

Rain-water,  39. 

Raisin  wine,  284. 

Raisins,  220. 

Rampion,  203. 

Raspberries,  208,  222. 

Raspberry  vinegar,  889. 

Ration,  emergency,  785;  for  profes- 
sional men,  820;  garrison,  784; 
in  foreign  armies,  786;  invalid, 
327,  328;  maximum  and  mini- 
mum, 18;  peace,  786;  of  single 
foods  compared,  330;  standard, 
796,  797;  tropical,  782;  war, 
307,  780;  work,  18. 

Rations,  calculation  of,  325;  United 
States  Army,  779;  U.  S.  Navy, 
790. 

Raw  meat  diet,  893. 

Rectal   absorption,  450. 

Rectal  feeding,  450,  451. 

Rectum,  care  of,  454. 

Red  bean,   194. 

Red  grouper,  149. 

Red  snapper,  149. 

Reduction  cure  for  obesity,  708. 

Reduction  feeding,  340. 

Reformatory  diet,  New  York  State, 
798. 

Refrigeration,  310. 

Regularity  in  feeding,  445. 

Regulin,  638. 

Reindeer  milk,  63. 

Relapses  in  typhoid  fever,  486. 

Renal  diseases,  diet  in,  543. 

Rennet,  83,  903;  test  for,  577. 

Rennin,  83. 

Respiratory  diseases  diet,  518. 

Rest  cure,  667. 

"Restricted  diet,"  336. 

Revalenta  Arabica,  186,  195. 

Rhachitis,  759-762. 

Rheumatism,  and  anemia,  771;  acute, 
712,  713;  chronic,  714. 

Rhine  wines,  281. 

Rhubarb,  204. 

Rice,  160,  183. 


INDEX 


925 


Rice  cream,  901. 

Rice  flour,  168. 

Rice  gruel,  900. 

Rice  milk,  900. 

Rice  soup,  898. 

Rice  water,  887. 

Rickets,  759. 

Ridge's  food,  174. 

Riegel     and     Leube's     test     dinner, 

572. 

River  water,  39. 
Roasting,  299. 

Robinson's  patent  barley,   174. 
Roe,  150. 

Roosevelt  Hospital  dietary,  872. 
Root  beer,  244. 
Roots,  196. 
Roquefort,  117. 
Rosacea,  689. 

Rotch's  milk  formulas,   106. 
Roundworm,  413. 
Rudisch's  beef  peptone,  134. 
Rules  for  feeding,  444. 
Rum,  286. 
Rye,  181. 
Rye  flour,  160. 

Saccharin,  159;  in  diabetes,  753. 

Saccharomyces  cerevisise,   165. 

Saccharose,   154. 

Saffron,  293,  429. 

Sage  cheese,  117. 

Sago,   187. 

Sahli's  test  for  free  hydrochloric  acid, 

575. 

Sake",  285. 
Salep,  187. 

Saline  waters  in  gout,  728. 
Salisbury  diet,  806. 
Salmon,   149. 
Salsify,  200. 
Salt,  celery,  203. 
Salt-free  diet,  47,  556. 
Salting,  309. 
Salts,  18;   deprivation  of,  45;  excess 

of,    45;    required,    332;    uses    of, 

44;  varieties  of,  44. 
Samp,    182. 
Sanatogen,   135. 
Sandwiches,  scraped  beef,  894. 


Sanose,  119. 

Sarcopeptone,  134. 

Sardines,  149. 

Sarsaparilla,  243. 

Sauces,  293. 

Sauerkraut,  202. 

Sausage  poisoning,  420. 

Savoury  and  Moore's  infant  food,  176; 

peptones,  139. 
Scalded  milk,  87. 
Scallops,  151. 
Scarlet  fever,  489. 
School  dietaries,  858. 
Schroth's  dry  cure,  807. 
Schumacher's  food,  174. 
Schweizer  cheese,  117. 
Schweninger  system,  702. 
Scotch  broth,  899. 
Scraped  beef,  893. 
Scraped  meat,  132. 
Scurvy,   763;    dietetic  treatment   for, 

766 ;  in  children,  766 ;  in  infants, 

765. 

Sea  food,  147. 
Seakale,  202. 
Seasickness,  605. 
Season  and  food,  318. 
Seegen's  almond  cakes,  751. 
Seltzer,   244. 
Semolino,    179. 
Sepsis,  diet  in,  775. 
Septicaemia,  502. 
Serving  of  food,  446. 
Sex  and  food,  323. 
Shad,  148,  149. 
Shaddock,  213. 
Shallots,  205. 

Shellfish,  151;  poisoning  by,  424. 
Sherry,  279. 
Ship  biscuits,  179. 
Shredded  wheat,  178. 
Shrimp,   151. 
Shrubb,   222. 
Sick  headache,  662. 
Sirup,  157. 
Size  and  food,  324. 
Skin  diseases  diet,  682. 
Skimmed  milk  cure,  795. 
Skimmed  milk  diet,  800. 
Sleep,  and  digestion,  380;  disordered, 


926 


INDEX 


672,  and  feeding,  448,  853;  and 
food,  479;  in  relation  to  meals, 
380. 

Slow  eating,  571. 

Smallpox,  488. 

Smalt,  113. 

Smelt,   149. 

Smoking,  309. 

Snipe,  144. 

Soda  crackers,  160. 

Sodium  benzoate,  315. 

Sodium  chloride,  46. 

"  Soft  diet,"  445. 

Somatose,   135. 

Sorghum,   156,   181. 

Sorrel,  203. 

Soups,  303,  891. 

Sour  mash,  285. 

Sour  milk,  91. 

Soused   fish,   313. 

South  American  beef  extract,  135. 

Soya  bean,  194. 

Soya  bread,   181. 

Spaghetti,   180. 

"  Special  diet,"  hospital,  863. 

Spices,   288,   291. 

Spirits,  265. 

Split  peas,   193. 

Spinach,  202. 

Squab,   144. 

Squash,  205. 

Stale  bread.  169. 

Standard  diet.  326. 

Starch,  160_;  foods,  containing,  159; 
percentage  of,  161 ;  potato,  197. 

Starches,  predigestion  of,  396. 

Starr's  dietaries  for  young  children, 
848,  849;  table  for  infant  feed- 
ing, 841. 

Starvation,  343-349. 

Steaming,  303. 

Stearins.   231. 

Sterilization,  98;  of  food,  311;  of 
milk,  99. 

Stewart's  diabetic  bread,  748. 

Stewing,   298. 

Stilton  cheese.  117. 

Stimulants.   241. 

Stoke's   mixture,   807. 

Stomach,    absorptive    power    of.    579; 


carcinoma  of,  611;  contents  of, 
examination,  572 ;  digestion  in, 
390,  392;  dilatation  of  and  elec- 
tricity, 602;  dilatation  of  and 
lavage,  598;  food  in  the,  386; 
motor  power  of,  578;  size  of  in- 
fants, 831. 

Stomatitis,  564. 

Stools,  infants',  616,  842. 

Stout,  275. 

Strawberries,  208,  209,  221. 

Stricture  of  oesophagus,  566. 

"  Strappings,"  59. 

Sturgeon,  149. 

Succi's  fast,  344. 

Sucrose,  154. 

Suet,  232. 

Sugar,  beet;  154;  cane,  154;  diet  of, 
22;  fruit,  207;  invert,  207;  ma- 
ple, 155;  substitutes  for  in  dia- 
betes, 753. 

Sugar  candy,    156. 

Sugars,  152. 

Sulphites,  316. 

Sulphur,  48. 

Sulphurous  acid  gas.  316. 

Superalimentation.   514. 

Suppositories,   food,  458. 

Suralimentation,  514;  in  insanity. 
681. 

Surgical  inflammation,  diet  in,  775. 

Surgical  operations,  diet  after,  772, 
773. 

Sweetbread,  145. 

Sweets  for  children,  859. 

Swiss  cheese,   117. 

Syntonin,   389. 

Syphilis,  518;  of  liver,  653 

Syrup,  157. 

Tabasco,  293. 

Taenia    mediocanellata.    414;    solium, 

414. 

Takadiastase,  397. 
Tamarind  whey,  889. 
Tamarinds,  216. 
Tania,  205. 
Tannin,   247. 
Tapeworm,  413. 
Tapioca,   160,  187. 


INDEX 


927 


Taro,  205. 

Tarragon,  203. 

Tea,  black,  248;  green,  248;  infusion 
of,  249 ;  preparation  of,  247 ; 
properties  of,  248;  substitutes 
for,  906;  therapeutic  action  of, 
249. 

Teeth  and  food,  355. 

Teething  and   food,   853. 

Temperature  and  digestion,  374;  and 
food,  375-377. 

Terrapin  eggs,   120. 

Test    for    intestinal    indigestion,    396. 

Test  breakfast,  573. 

Test  dinner,  572. 

Test  meals,  572. 

Tetanus,  504. 

Theobromine,  259. 

Thermos  bottle,  356. 

Thermotherapy,  375. 

Thirst,  42;  in  diabetes,  735;  in  ty- 
phoid fever,  480. 

Thompson's  dietary  tables,  777, 
778. 

Thyroid  extract  in  obesity,  710. 

Thyroid  gland,   145. 

Tissue  sparers,  8. 

Toast,  169. 

Tobacco  and  constipation,  641 ;  and 
food,  404. 

Tokay,   280. 

Tomatoes,  204. 

Tomcod,   149. 

Tongue,  141. 

Tonsilitis,  564. 

Torula   amara,  73. 

Tous-les-mois,    186. 

Tracheotomy,  495. 

Trained  purveyors  of  food,  462. 

Training  diet,  809. 

Travel  and  diet,  824. 

Treacle,  157. 

Trichina   spiralis,  415. 

Trichinosis,  415;   treatment  for,  418. 

Tripe,   145. 

Trisket,  178. 

Trommer's  extract  of  malt,   189. 

Tropon,    133. 

Trout,  148,  149. 

Truffles,  224. 


Trypsin,  394. 

Tubercular  meat  infection,  434. 

Tubercular  milk  infection,  432. 

Tuberculosis,  causation  of,  505;  ce- 
reals in,  509;  and  cod-liver  oil, 
509;  diet  in  advanced  cases  of, 
513;  in  mild  cases  of,  511;  die- 
tetic treatment  for,  505;  and  al- 
cohol, 510;  and  eggs,  509;  and 
gastric  catarrh,  771;  and  milk 
diet,  513;  meats  in,  508. 

Tubers,  196;  succulent,  200. 

TufnelPs  diet,  536. 

Tuna,  223. 

Turbot,  149. 

Turkey,   144. 

Turmeric,  429. 

Turnips,  200. 

Typhoid  fever,  alcohol  in,  481 ;  die- 
tetic treatment  for,  474;  feeding 
of  typical  cases,  485 ;  pathological 
physiology,  473. 

Typhoid  food  infection,  435. 

Typhus  fever,  488. 

Tyrotoxicon,  424. 

Ulcer  of  stomach,  607,  608. 

Ultramarine,  429. 

United  States  army  rations,  789. 

Uric  acid  diathesis,  559. 

Urinary  diseases,  diet  in,  543. 

Urine,    and    food,    403;    and    sugars, 

154. 

Urticaria,  684. 
Utica  State  Hospital  dietary,  876. 

Valentine's  meat  juice,  138,  141. 

Vanilla,  292. 

Veal,  141. 

Veal  broth,  892. 

Vegetable  foods,   152,   190. 

Vegetables,  canned,  312;  for  children, 
850;  in  chronic  constipation, 
636;  classification  of,  206;  com- 
position of,  201,  206;  dried,  306; 
in  gout,  723 ;  properties  of,  201 ; 
varieties  of,  20  L 

Vegetarianism,  33. 

Venison,   142. 

Vermicelli,  160. 


928 


INDEX 


Vermouth,   288. 

Vertigo,  673. 

Vichy,  244,  245. 

Vinegar,    292,    313. 

Viscera,  145. 

Vomiting,  603;  cyclic,  604;  of  preg- 
nancy, 607. 

Von  Noorden's  diet  for  diabetes,  757 ; 
oatmeal  diet,  757;  diet  for  obes- 
ity, 705. 

Walnuts,  226. 

Water,  19,  36 ;  alkaline,  243 ;  depriva- 
tion of,  42;  dietetic  uses  of,  40; 
effervescing,  243;  excess  of,  41; 
in  chronic  Bright's  disease,  554; 
in  diabetes,  754;  in  gout,  725; 
purity,  38;  quantity  per  diem, 
332;  temperature  of,  44;  uses  of, 
37;  varieties  of,  38. 

Water  starvation,  42. 

Waters,  acidulous,  246;  chalybeate, 
246 ;  in  chronic  constipation,  638 ; 
in  fevers,  468;  lithia,  245;  min- 
eral, 243;  table,  244;  thermal, 
244. 

Watermelons,  208. 

Weakfish,  149. 

Weaning,  837. 

Weighing  of  food,  34;  of  infants,  844. 

Weight  and  food,  324. 

Weissbeer,   275. 

Welch  rarebit,   118. 

Wet  nurse,  selection  of,  828. 

Wet  nurse's  diet,   829. 

Wheat   kernel,    162;    puffed,   184. 

Wheaten  bread,  169. 

WTheatena,   178. 


Whey,  116,  119;  cream  of  tartar,  889. 

Whey  cheese,  116. 

Wheyn,   120. 

Whisky,  285. 

WThite  beer,  275. 

Whitefish,  149. 

Whooping  cough,  491. 

Wine,  composition  of,  276;  mulled, 
889;  properties  of,  276. 

Wine  jelly,  905. 

W7ine  whey,  889. 

Wines,  acid,  281;  adulteration  of, 
286,  428;  aromatic,  281;  concen- 
trated, 283;  dry,  279,  282;  per- 
fect, 282;  red,  277;  rough,  283; 
Darkling,  281;  sweet,  280;  va- 
ieties  of,  279;  white,  277. 

Wintergreen,  293. 

Whortleberries,  202,  222. 

Woodcock,   144. 

Wood's  diet  for  neurasthenia,  670. 

Worcestershire  sauce,  293. 

Work  and  food,  332. 

Yam,  199. 

Yeast,    165, 

Yeast  fungus,  262. 

Yellow  fever,  499;  treatment  for,  501, 

502. 

Yeo  system  for  obesity,  703. 
Yohourd,  96. 
Yolk,   121. 

Zein,   182. 
Zoolak,  95. 
Zwieback,  171. 
Zymine,  140. 


(16) 


Date  Due 


T 


REC'D 


INTED  IN  u.s.4.  CAT.    NO.    24    161 


3  1970  00364 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


A  000441  122  9 


WBUOO 
TUT8p 

1909 
Thompson,  W     G 

Practical  dietetics  . . . 


Thompson,  W     G 

Practical  dietetics  , 


1909 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 
IRVINE,  CALIFORNIA  92664 


